​The independent auditor plays an important role in ensuring cooling water systems are compliant with the Risk Management Plan (RMP) and the Public Health Regulation 2022.

Last updated: 01 September 2022

Who is the independent auditor?

The auditor is a person who has:

  • completed training specified by NSW Health.
  • demonstrated appropriate qualifications and experience.
  • received approval from the Health Secretary.

The auditor must be independent of the:

  • occupier
  • risk assessor
  • duly qualified person
  • laboratory, and
  • a person employed or engaged by the person who employed or engaged a person referred to above.

What is the role of the independent auditor?

The Public Health Regulation 2022 requires an auditor to assess whether the occupier demonstrates compliance with the actions, control strategies, monitoring and timeframes required by the RMP (Approved Form 1), and mandatory actions required by the Regulation.

The auditor does not assess the quality of the risk assessment or compliance with any optional recommendations in the RMP that do not affect the risk of Legionella growth or transmission.

How often should audits be carried out?

The occupier must ensure that an audit takes place for each 12 month period, with no gaps between periods. The audit period commences on the first day of the month following the month in which the RMP was completed.

As the audit is a retrospective review of documents generated within the 12 month period, the Regulation allows for the audit to be completed within two months after the end of the audit period. For example, if the RMP was completed on 15 January, the audit period would commence on 1 February and end on 31 January the following year. The audit for this period would need to be completed by 31 March, using data and documentation from the 12 month audit period.

What is the process for conducting an audit?

The audit is a document-based review. It is not mandatory for the auditor to conduct an on-site inspection of the premises where the cooling water system is located.

There are seven key steps in the audit process:

  1. collect all documents generated within the 12 month audit period.
  2. list all actions required by the RMP and Regulation.
  3. assess compliance with actions required by the RMP and Regulation.
  4. assess compliance with the timeframes for actions required by the RMP and Regulation.
  5. determine whether the system is compliant, and make recommendations for addressing non-compliance.
  6. prepare an audit report using Approved Form 2, and provide the Certificate of audit completion to the occupier.
  7. local government authority may investigate non-compliant systems.

Which documents should the auditor review?

For the 12 month audit period, the auditor should review:

  • current RMP.
  • monthly reports covering inspection, maintenance (including servicing), chemical analysis, and microbial testing.
  • records of any actions taken to meet RMP requirements or address non-compliance identified by previous audit.
  • records of any notifications made to the local government authority (e.g. for a reportable test result).

The auditor should obtain these records from the occupier or the duly qualified person(s).

What activities should be audited?

When conducting an audit, the auditor should review:

  • actions, control strategies and monitoring required by the RMP.
  • sampling and testing for Legionella count and heterotrophic colony count, every month.
  • notifying the local government authority of a reportable test result, within 24 hours of receiving the result.
  • providing the local government authority with a certificate of RMP completion and certificate of audit completion, within 7 days of receiving the document.
  • preparing a monthly report of inspection, maintenance (including servicing), microbial testing, and chemical analysis, every month.

How should the audit be documented and notified to the local government authority?

The auditor must document their findings in the Audit report (Approved Form 2).

This includes a Certificate of audit completion which notes the outcome of the audit (compliant or non-compliant).

The occupier must provide the certificate to the local government authority within 7 days of completion of the audit.

The occupier may engage another person, such as the auditor or duly qualified person, to make this notification on their behalf.

How do I become an auditor?

Auditors must apply for approval to NSW Health using the Application for approval to audit cooling water systems (Approved Form 5).

Before applying, auditors must complete in full the TAFE NSW Legionella Control in Cooling Water Systems training program or an equivalent qualification.

For more information about the auditor application process in NSW, visit the Independent auditors of cooling water systems webpage.

How do I find an approved auditor?

The list of approved auditors will be available on the NSW Health website.

What further guidance and training is available?

The NSW Guidelines for Legionella Control in Cooling Water Systems explain the new requirements in detail, including the audit process.

This series of factsheets on Legionella Control in Cooling Water Systems provides key information for each stakeholder.

NSW Health has developed the Legionella Control in Cooling Water Systems training program together with TAFE NSW. It is compulsory for independent auditors to complete this training.

For more information

Current as at: Thursday 1 September 2022
Contact page owner: Environmental Health