HSE - systematic work

This document is an addition to NTNU’s HSE policy, and is intended as a common checklist for systematic HSE work in all units.

Norsk versjon - HMS – systematisk arbeid

This is one of three pages about NTNU's formal HSE policy.

1. HSE policy | 2. HSE – Systematic work | Subject page about HSE

HSE - Sytematick work

NTNU's HSE model

Illustration: NTNU's HSE model

1. Initiate

  • Take the initiative to get the work started.
  • Inform, motivate and take part.
  • Agree on tasks and authorities.
  • Establish goals.
  • Organize and plan systematic HSE work.

Take the initiative to get the work started: The line manager should initiate the systematic HSE work. This work should be performed in cooperation with the HSE coordinator (where applicable), the safety deputy and other employees.

Inform, motivate and take part: The employees should take part in the process. It is important that employees who have experience dealing with HSE challenges, contribute with their knowledge and suggestions.

Agree on tasks and authorities: An overview of HSE responsibilities, tasks and authority should be distributed and be available at the unit, see the description of HSE roles in the HSE policy, chapter 5.

Establish goals and a plan of action: The unit should establish a goal for its HSE work, and these goals should be founded in NTNU’s HSE policy. Local plans of action should also be established to reflect NTNU’s priorities, cf. the Annual HSE Report, as well as subjects that the unit wants to put on the agenda. At the turn of the year, the unit must assess whether it has reached its goals, and possibly establish new goals.

Organize and plan systematic HSE work: Appoint a diverse group, and make sure that one person is tasked with driving the work forward.

Ensure documentation:

  • Overview of the distribution of responsibilities, tasks and authorities at the unit (organisation)
  • Overview of concrete HSE tasks that are delegated, and to whom / which function

2. Mapping

  • Get an overview of applicable laws, regulations, HSE guidelines and other requirements.
  • Identify and assess HSE challenges.
  • Identify the need for HSE training.
  • Ensure documentation

Get an overview of applicable laws, regulations, HSE guidelines and other requirements: All units must have an overview of the requirements applicable for their own activities. The activities should be organized according to these requirements. For an overview of NTNU's HSE guidelines, see HSE guidelines – summary page.

Identify and assess HSE challenges: NTNU has four different tools to identify and assess HSE challenges:

  • Appraisal interview
  • Work environment survey
  • Risk assessment
  • Overview of HSE nonconformities

Using these tools forms the basis for plans of action. Plans of action and annual reports from previous years document HSE challenges and can be good sources of information.

Appraisal interview: The appraisal interview is a good tool to ensure a good working environment and work performance development. One of the basic ideas behind the appraisal interview is to inspire development by giving feedback to each employee on the current situation, and to facilitate the employee’s good performance, development and well-being in the period ahead. The interview is an addition to the regular employee-leader dialogue, and should be carried out annually.

The Innsida page Appraisal interview has more information about possible subjects for discussion, as well as a guide and a checklist for the interview.

Work environment survey: The work environment survey is carried out bi-annually to survey, follow up on and improve the psychosocial and organisational working environment. See Work environment survey for more information.

Risk assessment: A risk assessment is systematic review of factors that can cause unwanted incidents in the workplace.

A general mapping of hazardous activities should be carried out at all levels at NTNU. The mapping form (in Norwegian) can be used as an aid. Prioritise which tasks, activities or processes need a specific risk assessment.

A risk assessment (see template) is carried out to assess causes, probability and consequences of unwanted incidents related to tasks, activities or processes identified in the general mapping.

If the risk (probability x consequence) is unacceptable, measures must be taken.

Reporting HSE nonconformities: Situations that can cause, or have caused, injury/damage to humans or the environment should be reported as HSE nonconformities in the NTNU nonconformity system (in Norwegian). It is also possible to report suggestions for improvement. Maintenance needs, cleaning, consumable replenishment (paper, soap etc.), complaints about performed work (own alternative on sign-up form) are reported through the building services. See separate guidelines for nonconformities related to information security and privacy (in Norwegian).

An overview of HSE nonconformities can provide useful information about HSE challenges, and should be an important part of the preliminary work related to risk assessments.

See also:

Identify the need for HSE training: All leaders must have HSE training cf. the Working Environment Act § 3-5. The line manager is responsible for making sure that all employees who are responsible for leading or supervising other employees at the unit, or who are assigned the role of HSE coordinator or safety deputy, have the necessary competence, which is at least equivalent to the contents of the HSE platform. The line manager should assess the need for additional competence and make sure that this competence can be acquired. The line manager should also make sure that employees who function as radiation protection coordinators or substance database contact persons get the necessary training.

For more information about the requirements for training of leaders, safety deputies and members of the Working Environment Committee (WEC), see the Working Environment Act §3-5 and the regulation of organisation, management and partaking §§ 3-18, 3-19 and 3-20 (in Norwegian).

See also:

Ensure documentation: The results of these mappings must be documented.


  • Risk assessments
  • Minutes from HSE meetings (forums/committees)
  • Results from HSE processes
  • Overview of completed HSE training (participants, course contents, duration, etc.)
  • Fire protection documentation
  • HSE nonconformities

3. Planning and prioritizing measures

  • Local HSE procedures
  • Coordination agreement
  • Plans of action
  • Make sure the necessary documentation is available.

Local HSE procedures: If NTNU’s HSE guidelines are insufficient and cannot be adjusted to meet the unit's needs, the unit can create local HSE procedures. The HSE procedures should, if possible, be implemented at the faculty level.

Coordination agreement: Where NTNU shares facilities/activities with other establishments, e.g. SINTEF and St. Olavs Hospital, the line manager must make sure that written agreements are made between the establishments. The agreement should state which establishment is considered the main establishment. The main establishment is responsible for coordinating the HSE work in the common facilities/activities. The coordination agreement shall be made in writing and signed by the manager and safety deputy of each establishment. The agreement must be documented. See the Coordination agreement for more information.

Plans of action: A plan of action should provide an overview of measures to be initiated, as well as costs, responsibilities and deadlines.

Ensure documentation: The following should be documented in NTNU’s archives:

  • Plans of action
  • Local procedures
  • Coordination agreements

4. Follow-up

  • HSE process
  • Nonconformity management
  • Indicators
  • Annual review of the HSE system

HSE process: The HSE process is a check of the current working conditions. The HSE process is designed to check whether measures identified during the risk assessment have been implemented and work as intended. Findings from the HSE process can be used as a basis for revising the risk assessment or conducting a new one. The HSE process should be performed at least once a year.

Nonconformity management: NTNU has a digital system for reporting and managing HSE nonconformities (in Norwegian). The overview of HSE nonconformities provides an opportunity to identify trends and make sure that nonconformities are managed and measures prioritised, as well as learning opportunities across the organisation. See also HSE nonconformities under Surveys (in Norwegian). An overview of reported nonconformities is presented to AMU and the Board every four months.

Annual review: The regulation of systematic health, safety and environment work in establishments requires the establishment to carry out and document systematic monitoring and review of the internal control, to make sure it works as intended (§ 5).

The Rector (at the HSE Division) should perform an annual review of the HSE system and make sure that it:

  • is in accordance with legislation and internal requirements
  • is suitable to support NTNU’s HSE priorities
  • contributes to continuous improvement
  • is used and maintained

Any necessary changes in the HSE system must be assessed. The annual review is documented with an annual HSE report, which normally is reviewed by the Board in the month of March.

Participants in compiling the Annual HSE Report:

  • The HSE Division
  • Occupational Health Services
  • The senior safety representative

The Annual HSE Report should contain the following elements:

  • Priorities
  • NTNU’s systematic HSE work
  • Occupational Health Services’ work in the establishment
  • Supervision and checks performed by public authorities or external actors



Approved by the HSE Head of Section – 14 February 2020 – HMSR63

(last changed 25.02.20)

Page updated 15.05.2020