Framework

Safety Management System

1.0 Purpose
2.0 Scope
3.0 Framework
I 3.1 Leadership, participation, and consultation I 3.2 Planning | 3.3 Support and operation|
3.4 Performance evaluation | 3.5 Improvement I
4.0 Definitions

1.0 Purpose
This document provides an overview of the Safety Management System (SMS) used to manage health, safety
and wellbeing across the University, in compliance with the Work Health and Safety Act, Regulations and Codes
of Practice.

Implementation of the framework will provide Griffith University with a systematic approach to providing a safe
and healthy workplace, prevent work-related injury and ill health, and continually improve its occupational health
and safety performance.

2.0 Scope
The framework requirements apply to all Griffith University staff, students, affiliates, and volunteers; all groups,
schools, research institutes and professional service elements; and all activities conducted by and on behalf of
the University.

3.0 Framework
This document aligns with the University Health, Safety and Wellbeing policy which outlines the University’s
commitment to Occupational, Health and Safety (OH&S), including roles, responsibilities, and delegations.
The framework is based on AS/NZS ISO
45001: Occupational health and safety
management systems – Requirements with
guidance and use, which applies the iterative
process of Plan-Do-Check-Act.
Planning allows OH&S risk, opportunities,
objectives, and processes to be assessed and
determined. The planned processes are then
implemented. Monitoring and measurement is
conducted to check that the intended outcomes
are being achieved, followed by further actions
to achieve continual OH&S performance
improvement.
This framework is considered in the context of
the University being a complex high-reliability
organisation, where people create safety under
dynamic, uncertain, and complex conditions.

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 3.1 Leadership, participation, and consultation
The university demonstrates commitment to health and safety by ensuring:

▪ Senior management involvement in the University Health & Safety committee, which takes primary
responsibility and accountability for the prevention of work-related injury and ill health and monitors
the performance of OH&S management systems. The committee reports to the University Executive
Group, University Council and the Vice Chancellor who takes ultimate responsibility and ensures
that OH&S policy and objectives are established and compatible with the strategic direction of the
university.

▪ The integration of the safety policies and procedures into operational areas through coordinated
group and local level Health & Safety committees and management structures, which includes
worker participation, consultation, and communication to confirm risk mitigation.

▪ The resourcing of a dedicated and integrated Health and Safety team to promote a proactive OH&S
culture, implement and maintain OH&S management systems, promote continual improvement and
OH&S initiatives, and support leaders to confirm that risks are identified, well managed and
organisational learnings from audits, incidents and other sources are communicated.

▪ Policies and procedures are in place to manage confidentiality, privacy, behaviour and due process
to ensure workers are protected from reprisals when reporting incidents, hazards, risks and
opportunities.

3.1.1 OH&S policy

The University Health, Safety & Wellbeing Policy supports the University’s commitment to ensuring
the health and safety of workers, students and others who are involved in or may be affected by
University activities. The policy broadly outlines the governance responsibilities and values it
commits to in relation to OH&S.

The University Workplace Rehabilitation Policy states the University’s values and commitment to
supporting the safe and timely return to work for all injured or ill staff.

3.1.2 Organisational roles, responsibilities, and authorities

Roles and responsibilities are detailed in the Work Health, Safety and Wellbeing Accountabilities,
and summarised below:

ROLE RESPONSIBILITY

Chancellor and University Council Responsible for exercising due diligence to ensure OH&S is effectively
implemented across the University.

Vice-Chancellor The Person Conducting a Business or Undertaking (PCBU) who has

primary duty of care in relation OH&S.

Executive Group Responsible for exercising due diligence to ensure OH&S is effectively
implemented across the University.

University Health, Safety & The committee is accountable for providing assurance and governance
Wellbeing Committee on Health, Safety and Wellbeing matters reporting to the Vice-
Chancellor and the Council via the Finance, Resource and Risk
Committee.

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University Biosafety Committee The committee is accountable for providing assurance and governance
on Biological Safety matters reporting to the Vice-Chancellor and the
Council via the Research Committee.

Group & Element Health, Safety & The committees are accountable for providing assurance and
Wellbeing Committees governance on Health, Safety and Wellbeing matters for their
respective areas.

Human Resources & Safety The Health and Safety team is accountable for ensuring Health and
Safety standards are set, communicated and for providing assurance,
guidance and support on Health and Safety matters.

Deans, Directors and Heads of Responsible for exercising due diligence to ensure OH&S is effectively
elements implemented across their respective operational areas.

Managers, Supervisors and Team Responsible for ensuring OH&S policy and procedure implementation
Leaders and compliance within their respective operational areas.

All Professional and Academic Responsible for taking reasonable care for the health and safety of
Staff themselves and other persons, and co-operating and complying with
any reasonable OH&S policy, procedure, or safety instruction.

Students, Visitors & Contractors Responsible for taking reasonable care for the health and safety of
themselves, and co-operating and complying with any reasonable
OH&S policy, procedure, or safety instruction.

3.1.3 Consultation and participation of workers

Consultation and non-managerial worker participation is facilitated by the requirement for

supervisors to engage in direct dialogue with workers including in assessing, managing and
approving and or communicating risk assessments. Group and local Health & Safety Committees
also require representation from a broad range of professional and academic staff members,
including students (where applicable). All persons are provided access to relevant training,
resources and information. OH&S policies and procedures, including confidential incident and
hazard reporting processes. Engagement with non-managerial workers is also encouraged in the
investigation of incidents and determination of corrective actions.

3.2 Planning
To ensure safety and legislative compliance, the University applies a risk-based planning approach to
the management of activities associated with the organisation. Particular attention must be given to
activities that are deemed to be high risk. Procedures and supporting documents are to be developed to
ensure that such requirements are transferred into operational level practices in an effective and timely
manner.

3.2.1 Actions to address risks and opportunities

All work areas and organisational units are required to conduct risk assessments to identify Health
and Safety hazards and hazardous activities to assess, prioritise and mitigate risks. Risk
assessments must be submitted to the GSafe risk register and approved by the relevant supervisor
and peer reviewed (if required). There is an opportunity to view and draw upon all risk assessments

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by other areas of the university as all risk assessments are shared across the central register (unless
deemed confidential).

Groups and business units are also required to maintain a risk register and action plan to manage
risks associated with identified hazards. The risk registers must be regularly reviewed, and the
effectiveness of controls monitored. Particular attention must be given to areas defined as ‘High
Risk Work Areas’ which are defined as locations where high-risk activities or processes are being
undertaken, or significant hazards exist such as chemical substances, gases or equipment.
Examples may include laboratories, clinical facilities, studios, or workshops.

3.2.2 Hazard Identification & Reporting

All staff and students are required to report any incidents, near misses or hazards via GSafe System
(Riskware). GSafe is used to record, notify, and facilitate the management of reports, which are then
reviewed by the relevant supervisor, business unit, Health and Safety consultant and safety
specialist (if required). Appropriate interventions are identified, and implementation is tracked
through an action plan.

Facilities and work areas must be inspected in accordance with the Guidelines for Workplace
Inspections. Generally, all work areas including office areas must be inspected annually as a
minimum. High risk workplaces such as workshops, laboratories, studios, and clinics may require
more frequent workplace inspections, for example following an incident or a non-compliance audit
from a Regulator. A risk assessment may also require a workplace is inspected more frequently.
Each Group is responsible for developing and implementing a workplace inspection schedule to
ensure that all work areas assigned to the Group are inspected. Checklists are provided to help
identify hazards that may arise from work areas or activities and take into account potential
emergency and other situations.

Laboratories must also be regularly audited by the University Safety Specialists, or upon request.
Regulated laboratories must be audited at least annually, and other laboratories progressively
inspected according to an audit schedule, upon request or after a significant incident. External
Regulators also conduct periodic audits of regulated laboratories.

The internal audit team also conduct periodic audits of the University Safety Management System
or other issues relating to OH&S to identify non-compliance or opportunities to enhance OH&S
performance, policies, procedures, governance, or systems.

Work-related psychosocial hazards must also be identified. Psychosocial hazards can arise from
organisational factors (work organisation, job design and poor workplace culture), environmental
factors and individual factors. In order to identify psychosocial hazards managers should have
conversations with workers, supervisors and health and safety specialists, consider how work is
carried out, noting any rushing, delays or work backlogs, observe how people interact with each
other during work activities, review relevant information and records such as reporting systems
including incident reports, workers’ compensation claims, staff surveys, absenteeism and staff
turnover data, and use surveys to gather information from workers, supervisors and managers.

3.2.3 Legal requirements

The university maintains a Register of Compliance Obligations to manage legislative and regulatory
obligations. In addition, Human Resources and Safety subscribe to law databases to monitor
changes to or admission of new legislation and/or regulations relating to OH&S. The University
Safety Consultants and Specialists are required to communicate information on new or amended
legislative obligations via the network of Health, Safety and Wellbeing Committees.

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 3.2.4 Planning action

The university ensures legal and other requirements are met as specified by the Compliance
Management Framework. In addition, the University completes business continuity plans in order to
prepare for and respond to emergency situations, in conjunction with the university wide Crisis
Management Plan and Emergency Management Plan.

3.2.5 OH&S Objectives

The University and Group Health, Safety and Wellbeing Committees are responsible for
establishing, monitoring, communicating, updating and evaluating OH&S objectives consistent with
the Health, Safety & Wellbeing policy and procedures. OH&S objective planning must consider;
what actions and resources are required; who will be responsible; the completion timeframe; and
how the results will be monitored and evaluated.

3.3 Support and operation

3.3.1 Support resources

The university shall determine and provide the resources needed for the establishment,
implementation, maintenance, and continual improvement of the OH&S management system and
associated resources.

3.3.2 Competence

The university will ensure staff and students are competent by providing appropriate education,
training, or experience. All workers are required to complete the University Health and Safety
Induction training module as well as a variety of other OH&S related modules as specified by the
University Training Matrix. Supervisors must ensure any additional relevant training or instruction
for required specific equipment, processes and activities is completed by workers before any
unsupervised work is permitted.

3.3.3 Awareness & Training

All staff and students are to be made aware of the university OH&S policies and objectives through
the mandatory online training modules, as well as via local area inductions. Training completions
are to be recorded in the GSafe Certifications register. Online training completions are recorded in
learning@griffith (Blackboard), then integrated into PeopleSoft and GSafe.

3.3.4 Communication

OH&S information must be communicated. Information may be distributed in a number of way

including via email, posted on the University website, noticeboards (if relevant) and circulated via
the relevant Health, Safety and Wellbeing Committees to operational areas. Information to be
communicated may include, but is not limited to OH&S alerts, committee documents, guidelines,
reports, and advice. Committee information is to be stored in relevant SharePoint, or Teams sites.

Information relating to Incidents, Audits, Risk Assessments, Licences and Training records are to
be submitted and maintained in the relevant GSafe registers which provides workflow notifications
to the relevant persons. Training records include all safety related online training modules, local area
inductions and may include training on specific equipment, first aid, warden or procedures. Policies,
Procedures, Guidelines are to be approved by the relevant university authority held in the University
policy library. In addition, links to Policies, Procedures, Guidelines, and other OH&S documents are
to be displayed on the University Health, Safety and Wellbeing website.
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For external organisations or contractors, the process for communication and consultation in relation
to OH&S matters, should be discussed and agreed upon by all parties during the contract negotiation
and engagement process.

3.3.5 Documented information

OH&S documentation is published in accordance with the Policy Governance Framework which
stipulates the consultation, review, delegation, format, identification and control of policies,
frameworks, guidelines, procedures, plans and local protocols. All University records must be
retained and disposed of in accordance with the University Records Management Policy and
Destruction of Digitised Records Policy.

3.3.6 Operational planning & control

Local safety plans must be established and implemented at all levels of the organisation, e.g.,
Group, School or Research Group to implement, control and maintain processes needed to
eliminate hazards or reduce OH&S risks. Safety action plans may be associated with a local or
element wide risk assessment and must stipulate the timeframe and who is responsible for
implementation. Action plans may also be associated with a risk register monitored by a Group or
University Committee. Wherever reasonably practical, an actions plan must follow the hierarchy of
controls to mitigate hazards and risk, by first seeking elimination, followed by substitution, then
engineering controls, then administrative controls and finally the use of Personal Protective
Equipment. Safety plans should be reviewed annually by the relevant Group HSW committee, in
conjunction with the relevant H&S Consultant and Senior HR Business partner.

3.3.7 Change Management

The university shall plan, communicate, and implement controls to manage temporary or permanent
changes that may impact OH&S performance. This may include changes to products, services,
processes, workplace locations, equipment, or the workforce. It also includes changes to knowledge
or information on hazards, risks, or legal requirements.

3.3.8 Procurement

Goods and services must be acquired in accordance with the University Purchasing Policy. All
potentially high-risk equipment or substance acquisitions are subject to ‘Special Approval’ in addition
to financial approval. Persons appointed as 'Special Approvers' have the responsibility to confirm
that a purchaser has appropriately managed the risks associated with the acquisition in accordance
with legislation and the university procurement guidelines, as outlined in the Special Approver
Guidelines. Chemical, biological, radioactive and scheduled substances are also contingent on the
completion of a risk assessment compliance with the Guidelines for Chemical Management.

3.3.9 Contractors

Contractors working at Griffith University are required to have the appropriate level of knowledge
and skills to perform the work or tasks they undertake. Where there is high risk work, Workplace
Health and Safety or other legislation demands specific training be done, contractors must be able
to produce evidence that they have been trained to the proper standards. These include: Working
at heights, Confined space entry, Tree felling, and Excavation.

Contractors must also have the appropriate safety equipment for the work with them on the job e.g.,
body harnesses suitable for the task, ladder tie-offs, gas detection equipment etc.

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 All building trade or maintenance contractors working on University sites must hold a current General
Safety Induction for Construction [Blue/White Card], as a minimum. University personnel, who are
authorised to bring contractors on site, are responsible for providing local site induction and
information regarding risks and expected preventative measures.

It is the responsibility of the Contractor to ensure that all of their own staff or subcontractors, who
are likely to work on our sites, are made aware of University procedures and standards, before they
begin work. This information is found in the Contractors and trade staff online induction.

3.3.10 Outsourcing

Where the University elects to outsource functions or processes, it shall ensure that such
arrangements are consistent with legal and other requirements associated with OH&S. Contracts
should confirm and stipulate OH&S requirements are consistent with the intentions of the University
Safety Management Framework.

3.3.11 Emergency preparedness and response

All staff must know how to report and respond to common emergency situations, including but not
limited to fire, medical emergencies, threats and weather events. Annual completion of Emergency
response and evacuation training is mandatory for all staff working on any campus. All persons
working in high-risk work areas, must also be aware of the emergency procedures relating to their
work area, including chemical, biological and other emergencies.

Building emergency procedures must be kept current and practiced annually in accordance with
AS3745-2010 Planning for emergencies in facilities and the Queensland Building Fire Regulation
2008. To support this, elements must appoint staff to fill local emergency roles, such as building
wardens and first aid officers. Appointed staff must be appropriately trained and allowed time to fulfill
their emergency duties.

3.4 Performance evaluation

3.4.1 Performance evaluation monitoring, measurement, and analysis

In order to evaluate and monitor the OH&S performance of the University, data is obtained from
systems including GSafe, SOLV Injury and learning@griffith to measure both leading and lagging
safety indicators. Data is compiled into interactive dashboards, extracted directly from source
systems, or collated from other sources such as the university Employee Assistance Provider. The
statistics are reported, analysed and any trends identified presented for discussion at Health, Safety
and Wellbeing Committees or in other management forums. Statistics include injury, hazard and
near miss data, as well as risk assessment reports, training completion and audit completion results.

3.4.2 Evaluation of compliance

Regular inspections of the workplace to evaluate OH&S compliance are conducted according to the
Guidelines for Workplace Inspections, which defines the inspection frequency, team, conduct and
reporting procedures. Furthermore, high-risk work areas, such as laboratories are regularly audited
by the University Safety Specialists, which includes the annual inspection of regulated laboratories
conducted on behalf of the University Biosafety Committee. Training compliance is also ensured by
linkage with the swipe-card access system for high-risk facilities.

Griffith maintains a register of legislation, regulations, standards, and policies with which the
University must comply. This Register of Compliance Obligations is the main tool used to identify

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 our obligations and the implications for Griffith’s activities and services and there is a process in
place to identify new and changing laws and regulations to keep the register updated.

Compliance Owners are identified in the Register of Compliance Obligations and are normally the
head of the operational area. They are responsible for ensuring compliance with specific obligations
in their area. There may be multiple Compliance Owners for certain obligations. There is also a
Compliance Manager that maintains the register and the Compliance Management Framework.
They also provide education and guidance to Compliance Owners to support them in fulfilling their
responsibilities.

3.4.3 Internal Audit

The university Internal Audit team provides independent advice and assurance on the effectiveness
of governance, risk management, and internal controls within the University. To remain independent,
internal audit do not have any direct responsibilities for, or authority over any of the activities which
it audits. They operate independently of senior management, reporting directly to Griffith’s Audit
Committee. An external quality assurance review of the internal audit function takes place every five
years.

3.4.4 Management review

Reports on the OH&S performance of the university are provided on a regular basis from the
University Health, Safety & Wellbeing Committee to the Executive Group, as well as to the Risk and
Audit Committee and University Council. Performance reports are also provided to the University
Research Committee from the University Biosafety Committee. In addition, all policies, frameworks,
guidelines and procedures are required to be reviewed at a minimum of 5-year intervals.

3.5 Improvement
3.5.1 Incident, nonconformity, and corrective actions

Action plans are completed for all inspections, audits and serious incidents, hazards or near misses.
Where appropriate, an investigation of an incident, or a review of a non-conformity is conducted to
inform intervention strategies. Actions are specified with completion deadlines and automatic
workflows notify the assigned person of the task(s) to be completed. Failure to complete an action
plan, or to complete assigned actions are escalated to ensure implementation.

3.5.2 Continual improvement

The university is committed to continual improvement of the suitability, adequacy, and effectiveness
of the OH&S management system. This is demonstrated through regular audits and reviews, worker
participation, surveys, performance monitoring, and the maintenance and retention of documented
information.

4.0 Definitions
For the purposes of this framework and related policy documents, the following definitions apply:
Reasonably practicable refers to what can reasonably be done in the circumstances when complying with duties
to ensure health and safety under legislation.

Senior management are people that may hold the following positions within the University: Deputy Vice
Chancellors, Pro Vice Chancellors, Deans, Administrative Directors, Heads, Heads of School, Centre Directors,
Directors and Associate Directors.

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Staff refers to both paid and unpaid people undertaking work for, or on behalf of, the University.

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INFORMATION Printable version (PDF) Downloadable version (Word)

Title Safety Management System Framework

Document number 2021/0000110

Purpose This document provides an overview of the Safety Management System

(SMS) used to manage health and safety across the University, in compliance
with the Work Health and Safety Act, Regulations and Codes of Practice.
Implementation of the framework will provide Griffith University with a
systematic approach to a safe and healthy workplace, prevent work-related
injury and ill health, and continually improve its occupational health and safety
performance.

Audience Staff

Category Governance

Subcategory Risk

Approval date 19 August 2021

Effective date 19 August 2021

Review date 2026

Policy advisor Senior Manager Health and Safety

Approving authority University Health, Safety and Wellbeing Committee

RELATED POLICY DOCUMENTS AND SUPPORTING DOCUMENTS

Legislation Building Fire Safety Regulation 2008

Codes of Practice
Codes of Practice for Electrical Work
Electrical Safety Act 2002
Electrical Safety Regulation 2013
Queensland Building Fire Safety Regulation 2008
Work Health and Safety Act 2011
Work Health and Safety Regulation 2011
Work Health and Safety (codes of Practice) Notice 2011
Workers Compensation and Rehabilitation Act 2003
Workers Compensation and Rehabilitation Regulation 2014

Policy Business Continuity Management and Resilience Policy

Children in the Workplace Policy
Construction Work Policy
Code of Conduct
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 Compliance Management Framework
Domestic and Family Violence Support Policy
Enterprise Risk Management Framework
Enterprise Risk Management Policy
Equity Diversity and Inclusion Policy
Griffith Health Intramural Professional Practice Policy
No Smoking Policy
Public Interest Disclosure Policy
Purchasing Policy
Reasonable Adjustments for Assessment – Students with Disabilities Policy
Register of Compliance Obligations
Student Wellbeing and Safety Policy
Student Critical Incident Management Policy
Student Sexual Assault, Harassment, Bullying and Discrimination Policy
Students with Disabilities Policy
Student Misconduct Policy
Staff Harassment Bullying and Discrimination Policy
Staff Sexual Assault and Sexual Harassment Policy
https://sharepointpubstor.blob.core.windows.net/policylibrary-prod/University
Campus Access and Use Policy.pdfWork-Integrated Learning at Griffith
Workplace Rehabilitation Policy
Vaccine Preventable Diseases Policy for Griffith Health Clinics

Procedures Crisis Management Plan

Emergency-Management-Plan
Electrical Safety Procedure
Electrical Safety Procedure Test and Tag
Guidelines for Chemical Management
Guidelines for the Prevention and Control of Communicable and Notifiable
Diseases
Guidelines for Workplace Inspections
Reporting and recording procedures for incidents, injuries, illness, hazards or
near misses
Reporting and Resolution of Staff Sexual Assault Harassment Bullying and
Discrimination Procedures
Special Approver Guidelines
Student Misconduct Procedures
Student Critical Incident Management Procedure
Student Wellbeing and Safety Procedures
The Responsible Conduct of Research
Workers Compensation Procedures
Workplace Rehabilitation Procedures

Local protocols N/A

Forms N/A

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