Audit of Occupational Health and Safety

Executive Summary

Background

Public Safety Canada (PS) is responsible for, and committed to, providing a safe work environment for all its employees. Promotion of safe working conditions and compliance with regulations are key components of health and safety in the work place. The Canada Labour Code - Part II Occupational Health and Safety (OHS) is intended to help prevent accidents and injury in the course of employment.1 The Canada Labour Code (CLC) Part II and its related regulations2, form the basis for the PS's OHS mandate.

A comprehensive OHS program is required to help ensure compliance with associated regulations, as prescribed by the CLC – Part II. This program must address the minimum legal requirements of the CLC II and related regulations.

PS's senior executives, managers and supervisors share specific OHS responsibilities which they are expected to carry out. These tasks help ensure the safety of staff, visitors and contractors in their area of responsibility. Management (the Employer) is supported by the OHS committees and Health and Safety Representatives, who also have health and safety monitoring and oversight responsibilities.

Audit Objective and Scope

The objective of this audit was to provide assurance that the existing management control framework ensures compliance with applicable occupational health and safety laws, regulations, and policies including the Canada Labour Code Part II, as well as the Treasury Board Policy on Occupational Safety and Health.

The scope of the audit included control activities in support of the key OHS legal requirements, including:

• OHS Committees and Health and Safety Representatives;
• Training and Awareness; and,
• Incident Reporting.

The audit covered the period of January 1, 2012 to December 31, 2013 as some OHS requirements encompass a two-year calendar period.

Summary of Findings

Overall, PS employees operate in office environments which represent a lower risk with minimal hazards as compared to other Departments who deal with such issues as heavy machinery or chemicals. The audit identified a number of good practices such as developed health and safety policies and procedures, established OHS committees and regional representatives and mandatory health and safety training.

The existing management control framework could be improved to ensure minimum legal requirements are met. Key legislative requirements such as frequency of OHS committee meetings and work place inspections were not fully being adhered to. The legislative compliance issues noted have not directly led to safety concerns or incidents at PS. However, if a severe incident were to occur, PS management could be found liable. Improved monitoring and reporting activities as well as augmented health and safety awareness initiatives would enable greater compliance to minimum legal requirements.

Health and Safety Committees and Monitoring Activities:

OHS Committees and Representatives have been established as required by legislation. Policy and Health and Safety Committee meetings covered relevant topics to help prevent and address health and safety concerns. However, work place committees were not meeting as frequently as required by legislation.

Additionally, the health and safety committees were not participating in or being consulted on a number of OHS topics that are required by legislation including the monitoring of data on work accidents, injuries and health hazards.

Effective monitoring processes, assessment of results, and corrective measures help ensure minimum legislative requirements are being met. Audit testing revealed monitoring procedures were lacking in some key areas including frequency of committee meetings, training participation rates and completion of work place inspections.

Work Place Inspections:

Health and Safety Representatives and/or OHS Committees are required by legislation to inspect each month, all or part of the work place. The results of interviews indicated that these inspections were being performed in the National Capital Region, but only documented when issues were found. Further, regions visited indicated that they were not aware that work place inspections were required.

OHS Training Programs:

Occupational Health and Safety training is offered to all employees through the Canada School of Public Service. Training covered the roles and responsibilities of the employees, employer, manager or supervisor, and OHS committees and representatives. It also discussed “Due Care & Diligence” for communicating accountabilities of all parties involved.

No evidence was found that training programs for employees covered provisions for awareness of emergency procedures and violence prevention. In addition, there is no specific training provided to the regional Health and Safety Representatives, and as a result, they are not fully aware of their roles and responsibilities. Subsequent to the audit period, Violence Prevention training was offered.

Incident Reporting:

PS has incident reporting procedures in place and a listing of OHS incidents are maintained by the Labour Relations and Wellness Group. Incidents were not reported from PS regional offices over the two year audit scope period. During face-to-face interviews, it was noted that employees had cut themselves, fallen, and experienced other incidents; in most cases the Health and Safety representative was informed but the incidents were not formally reported. This alludes to regional employees not being fully aware of the incident reporting process.

Additionally, required legal forms such as the Workers Compensation Board Report and Hazardous Occurrence Investigation Report (HOIR) were not always completed for incidents reported.

Audit Opinion

In my opinion, the existing management control framework was generally compliant with applicable occupational health and safety laws, regulations, and policies including the Canada Labour Code Part II, as well as the Treasury Board Policy on Occupational Safety and Health. The audit identified a number of good practices such as developed health and safety policies and procedures, established OHS committees with regional representatives, and mandatory health and safety training. There are opportunities to improve the management control framework to better demonstrate that legal requirements are met.

Statement of Conformance and Assurance

The audit conforms to the Internal Auditing Standards for the Government of Canada, as supported by the results of the quality assurance and improvement program.

In my professional judgment as Chief Audit Executive, sufficient and appropriate audit procedures have been conducted and evidence gathered to support the accuracy of the opinion provided and contained in this report. The opinion is based on a comparison of the conditions, as they existed at the time, against pre-established audit criteria that were agreed upon with management. The opinion is applicable only to the entity examined.

Recommendations:

1. The Assistant Deputy Minister, Corporate Management Branch, should strengthen the monitoring processes by undertaking the following:
   • Identifying key health and safety compliance requirements that would benefit from risk-based monitoring; and
   • Establishing ongoing reporting mechanisms to inform management of the progress towards meeting the key health and safety compliance requirements.
2. The Assistant Deputy Minister, Corporate Management Branch, should develop procedures for conducting work place inspections. The procedures could include:
   • Roles and responsibilities;
   • Frequency of inspection;
   • Documentation standards (e.g. template for report results, capturing action items); and,
   • Information management requirements.
3. The Assistant Deputy Minister, Corporate Management Branch, should strengthen the occupational health and safety training program, including:
   • Developing annual target completion rates for mandatory employee training; and,
   • Developing and administering training for Health and Safety Representatives.
4. The Assistant Deputy Minister, Corporate Management Branch, should strengthen the incident reporting process by:
   • Increasing the level of awareness and importance of incident reporting in the regions; and,
   • Developing and implementing information management requirements for required documentation when incidents occur.

Management Response

Management accepts all recommendations and will implement the actions.

CAE Signature

____________________________

Audit Team Members
Contractors – Raymond Chabot Grant Thornton Consulting Inc.
Deborah Duhn
Kyle Abonasara

Acknowledgements
Internal Audit would like to thank the all those who provided advice and assistance during the audit.

1. Introduction

1.1 Background

Public Safety Canada (PS) provides strategic policy advice on national security, border strategies, crime prevention and emergency management. The Department also delivers a number of grant and contribution programs related to emergency management and community safety. To deliver on its mandate, PS operates in nineteen offices across the country located in all provinces and in the North, and houses approximately 1,223 employees. These offices are organized into six regions: Atlantic, Quebec, Ontario, Prairies, British Columbia and the North.

As part of the Risk Based Audit Plan approved on September 26, 2013, PS identified OHS as an area that should be audited in 2013-14. Senior Management required assurance that OHS programs are functioning appropriately, ensuring the safety of employees and compliance to applicable regulations. There has been no previous OHS audit.

It should be noted that overall, PS employees operate in office environments which represent a lower risk with minimal hazards as compared to other Departments who deal with such issues as heavy machinery or chemicals.

1.2 Legislative Framework

PS is responsible for and committed to providing a safe working environment for all of its employees. Promotion of safe working conditions and compliance to regulations are key components of health and safety in the work place. The Canada Labour Code - Part II Occupational Health and Safety is intended to help prevent accidents and injury in the course of employment.3 The CLC Part II and its related regulations4, form the basis for PS's OHS mandate.

An OHS program is required to help ensure compliance with OHS regulations, as prescribed by the CLC – Part II. This program must address the minimum legal requirements of the CLC -- Part II and related regulations. Examples of topics covered by the CLC - Part II include, but are not limited to:

• hazard prevention;
• training and awareness;
• incident reporting;
• protective materials, equipment, devices, clothing;
• OHS Committees and Representatives;
• employer responsibilities with respect to OHS (including responsibilities to OHS Committees and Representatives);
• facilities;
• first aid;
• vehicles;
• emergency preparedness; and,
• violence in the work place.

1.3 Roles and Responsibilities

PS's senior executives, managers and supervisors share specific OHS responsibilities which they are expected to carry out. At Public Safety, responsibility for OHS falls under the control of the Corporate Management Branch, specifically to the Human Resources Directorate. Specific health and safety roles and responsibilities are further outlined in the table below:

1.4 Audit Objective

The objective of this audit was to provide assurance that the management control framework in place ensures compliance with applicable occupational health and safety laws, regulations, and policies including the Canada Labour Code Part II, as well as the Treasury Board Policy on Occupational Health and Safety.

1.5 Risk Assessment

The risk assessment conducted in the planning stages informed the development of the audit scope and criteria.
Occupational health and safety (OHS) is governed by legal requirements and affects all employees. Overall risk areas have been divided into two (2) main categories;

• Legal: Risk that Public Safety Canada (PS) does not meet legal requirements
• People: Risk of injury, illness or death.

Public Safety Canada employees carry out their work duties in an environment where there is generally a low risk of injury, illness or death. In general, there is predominately one type of PS work environment: Office.
This audit focused predominately on the legal risk since, as noted above, PS employees work in an environment that is generally considered safe and low risk. However, the risk of non-compliance with legislative requirements is high.

1.6 Scope

The audit covered the period of January 1, 2012 to December 31, 2013 as some OHS requirements cover a two-year calendar period.
The scope of the audit included control activities in support of the key OHS legal requirements, including:

• OHS committees and health and safety representatives;
• training and awareness; and,
• incident reporting.

1.7 Audit Opinion

In my opinion, the existing management control framework was generally compliant with applicable occupational health and safety laws, regulations, and policies including the Canada Labour Code Part II, as well as the Treasury Board Policy on Occupational Safety and Health. The audit identified a number of good practices such as developed health and safety policies and procedures, established OHS committees with regional representatives, and mandatory health and safety training. There are opportunities for improving the management control framework to better demonstrate that legal requirements are met.

1.8 Statement of Conformance and Assurance

The audit conforms to the Internal Auditing Standards for the Government of Canada, as supported by the results of the quality assurance and improvement program.

In my professional judgment as Chief Audit Executive, sufficient and appropriate audit procedures have been conducted and evidence gathered to support the accuracy of the opinion provided and contained in this report. The opinion is based on a comparison of the conditions, as they existed at the time, against pre-established audit criteria that were agreed upon with management. The opinion is applicable only to the entity examined.

2. Findings, Recommendations and management responses

Overall, PS employees operate in office environments which represent a lower risk with minimal hazards as compared to other Departments who deal with such issues as heavy machinery or chemicals. The audit identified a number of good practices such as developed health and safety policies and procedures, established OHS committees and regional representatives and mandatory health and safety training.

The existing management control framework could be improved to ensure minimum legal requirements are met. Key legislative requirements such as frequency of OHS committee meetings and work place inspections were not fully being adhered to. The legislative compliance issues noted have not directly led to safety concerns or incidents at PS. However, if a severe incident were to occur, PS management could be found liable. Improved monitoring and reporting activities as well as augmented health and safety awareness initiatives would enable greater compliance to minimum legal requirements.

2.1 Health and Safety Committees and Representatives

The audit expected to find that effective OHS committees and health and safety representatives were in place and operating in compliance with the Canada Labour Code – Part II. As part of assessing the effectiveness of committees, the audit expected to find monitoring and oversight practices in place to help ensure compliance with legislative requirements.

Health and Safety Committees and Representatives

Occupational Health and Safety Regulations require that health and safety representatives be appointed and/or OHS committees be established at the work place. PS has established an OHS Policy Committee, and for each work place with more than 20 employees, an OHS work place committee. For all PS work places with 20 or fewer employees, a health and safety representative has been appointed. Additionally, terms of reference have also been established for all OHS policy and work place committees.

Committee meetings covered relevant topics to help prevent and address health and safety concerns. Discussion topics included:

• Development of health and safety policies and procedures;
• Issues brought forward by employees;
• Disposition of OHS related complaints; and,
• Results of monthly work place inspection reports.

According to the CLC Part II, OHS committees are required to meet at least quarterly for Policy Committees, and nine times per year for work place committees6. While the Policy Committee and the Work Place Committee – 257 Slater met as required, the remaining two committees did not. The following table outlines the requirements and actual number of times the committees met during 2012 and 2013:

The absence of regular meetings may indicate that health and safety issues and complaints are not discussed and/or addressed in a timely manner, resulting in the potential of employees, visitors and contractors being exposed to hazards that may affect their health and safety. Management indicated that it was difficult to obtain quorum which resulted in the cancellation of meetings throughout the year.

Additionally, there was no evidence in the minutes to suggest that the committees participated in or consulted on a number of required OHS-regulations9 during the audit period, particularly around the monitoring of data on work accidents, injuries and health hazards.

Monthly Inspections:

Health and safety representatives and/or OHS committees are required by regulation to inspect, each month, all or part of the work place, and ensure that every part of the work place is inspected at least once each year. Periodic inspections of the work place enable an organization to identify and address hazards in a timely manner. The CLC part II 136 (5) (j) states that health and safety representatives shall inspect each month all or part of the work place, so that every part of the work place is inspected at least once each year10. This means that if all reports were completed there would be twelve monthly reports, one for each month for the nineteen specific PS locations, for each year in the scope of the audit, totalling four hundred and fifty six individual reports.

Interviewees indicated that monthly inspections were being done in the National Capital Region (NCR) however they were not being conducted within the regional offices. The audit requested supporting documentation of all the inspections that should have been conducted over the scope period, in the NCR and regionally; only four of the mandatory four hundred and fifty six reports were obtained, all of which related to 257 Slater Street in Ottawa.

The lack of documented evidence of the monthly inspections may be due to documentation standards that were not clearly defined. NCR management in Labour Relations indicated that if issues were not found, a monthly inspection report would not be generated and maintained. However PS is required to demonstrate compliance to legislation and therefore some form of evidence is necessary. In addition, Health and Safety Representatives have not received training on their responsibilities regarding monthly inspections which may have contributed to the lack of monthly inspections performed in the regional offices.

Although NCR Labour Relations management indicated that monthly inspections were being performed, they advised the auditors that no health and safety issues had been identified. The audit conducted random inspections nationally and in the regions and found some minor health and safety observations. These included:

• Missing ceiling tile with exposed wiring;
• Boxes or other materials not safely stacked;
• First aid kits not complete or usage log not used; and,
• Cabinets opening into narrow, high traffic areas.

Given there were no documented reports, we cannot conclude whether these observations were present during the monthly inspections. Further, the audit noted that while some of these issues may not in and of themselves create a health and safety issue, the identification of these observations should have been noted and appropriately concluded as to whether a risk existed or not.

Monitoring:

Effective monitoring processes, assessment of results, and corrective measures help ensure minimum legal requirements are being met. Monitoring of health and safety is a shared responsibility between various individuals/committees including the Director General, Human Resources, Health and Safety Committees and senior management.

Audit testing revealed limited monitoring procedures are in place to help ensure a safe work environment and that legislative requirements are being met. Monitoring procedures were lacking in the following areas:

• General compliance requirements (e.g. frequency of health and safety committee meetings); and,
• Health and safety training completion rates; and,
• Statistics and/or trend analysis on reported incidents.

Recommendations:

1. The Assistant Deputy Minister, Corporate Management Branch, should strengthen the monitoring processes by undertaking the following:
   • Identifying key health and safety compliance requirements that would benefit from risk-based monitoring; and,
   • Establishing ongoing reporting mechanisms to inform management of the progress towards meeting the key health and safety compliance requirements.
2. The Assistant Deputy Minister, Corporate Management Branch, should develop procedures for conducting work place inspections. The procedures could include:
   • Roles and responsibilities;
   • Frequency of inspection;
   • Documentation standards (e.g. template for report results, capturing action items); and,
   • Information management requirements.

2.2 Training and Awareness

The audit expected to find effective training and awareness programs in place and in compliance with the Canada Labour Code – Part II and the Treasury Board Policy on Occupational Health and Safety. The audit also expected to find that these programs covered OHS roles, responsibilities and accountabilities and included hazard awareness and prevention measures to help ensure compliance with legislative requirements.

Awareness Information

Internal health and safety policies (including the Policy on the Prevention of Violence in the Workplace and the Public Safety Canada Health and Safety Handbook) have been developed and can be accessed by employees through the PS intranet (Info-Central). Health and safety areas covered in these documents include:

• Employer and employee health and safety roles and responsibilities;
• Incident reporting;
• Requirements and expectations for Personal Protective Equipment; and,
• Work place Hazardous Materials Information System (WHMIS) and roles and responsibilities for WHMIS training.

Employee / Employer Training

In accordance with the Treasury Board Policy on Occupational Health and Safety, Departments must provide OHS training and information to employees. OHS training is offered to all employees online through the Canada School of Public Service (CSPS). The availability of this online training course was communicated to all employees and managers as a mandatory requirement, through an internal e-newsletter. CSPS OHS Training outlined the roles and responsibilities of the employees, employer, manager or supervisor, and OHS committees and representatives. It also discussed “Due Care & Diligence” for communicating accountabilities of all parties involved.

The participation objective (target completion rate) for the mandatory on-line training has not been defined by PS. To date, approximately 142 (11% of PS) employees have completed the training. Additionally, responsibilities to monitor completion rates have not been defined resulting in no active monitoring of completion rates by PS management.

In order to comply with legislative and policy requirements, PS developed, implemented and is monitoring a Hazard Prevention Program that also educates all employees in health and safety matters11.

The CLC Part II prescribes specific areas that should be covered in the OHS training and awareness programs. Training and awareness material reviewed did not cover key OHS topics including the provisions for personal protective equipment, clothing, devices or materials, awareness of emergency procedures, and violence prevention. As such, employees may not be fully aware of general safety procedures and their rights under CLC Part II12.

OHS Committee and Representative Training

The Policy Committee is required to maintain a listing of committee members who have completed the training. Not all members were able to attend the first session in the spring of 2013, so an additional session was offered in the fall to ensure all members had the opportunity to complete this training. However, the audit was unable to find any evidence, such as the list, to validate how many committee members had completed the training.

Training offered specifically for OHS committee member's outlines the functions and roles of the Work Place Committee and Policy Committee Representatives. It also discusses “Due Care & Diligence” for communicating accountabilities of all parties involved.

The CSPS employee OHS training and OHS committee training cover the employer's responsibility to develop, implement, and monitor a prescribed program for the prevention of hazards.

In the past, training for OHS Committees was provided on an annual basis. However, the frequency of the course offering was reduced due to lack of attendance. Currently, training is offered when there is a major turnover in committee membership.

There is no specific training provided for the Regional Health and Safety Representatives. As a result, Health and Safety Representatives were not fully aware of their roles and responsibilities (e.g. monthly inspections).

Recommendations:

3. The Assistant Deputy Minister, Corporate Management Branch, should strengthen the occupational health and safety training program, including:
   • Developing annual target completion rates for mandatory employee training; and,
   • Developing and administering training for Health and Safety Representatives.

2.3 Incident Reporting

The audit expected to find a prescribed program for incident reporting that is well developed, implemented and monitored.

The Canada Labour Code Part II13 and PS health and safety policies require that employees report to their employer every incident or hazardous occurrence encountered in the course of their work that has or is likely to cause an injury. It also requires that employers investigate, record and report, in the manner and to the authorities as prescribed, all accidents, occupational diseases and other hazardous occurrences known to the employer.

Incident Reporting Policies

PS has in place, a formal incident reporting process for accidents and violence-related incidents in the work place. The processes are documented in the following two policies:

• Policy for Accidents and Incidents in the Workplace: this document defines both the employee's and management's responsibilities, outlines the procedures for reporting a work place accident or incident; and details investigation requirements. Additionally, it outlines specific procedures for dealing with a critical accident.
• The Policy on the Prevention of Violence in the Workplace: this document works in conjunction with the Policy on Harassment Prevention and Resolution. The Policy outlines key policy requirements, roles and responsibilities for managers, directors and supervisors and provides information about how to report a violent incident.

Monitoring and Reporting:

The Labour Relations and Wellness Group is responsible for maintaining a log of OHS-related incidents. The log should include the location and description of the incident, dates when the Hazardous Occurrence Investigation Report (HOIR) was completed, and whether the forms were sent to Employment and Social Development Canada. In reviewing the departmental log, while there were reported NCR incidents, there were no incidents reported within the regions. This may indicate that regional employees may not be fully aware of the incident reporting process.

PS internal policies require a Workers Compensation Board Report 14 and a HOIR to be completed for every incident. In calendar year 2012 and 2013 there were 41 incidents logged by the Labour Relations and Wellness Group. Of the 41 incidents logged, an audit sample of ten HOIRs was requested from the Labour Relations and Wellness Group for testing. Three of the ten sampled HOIRs were provided, indicating that only 30% of the reports were completed, and/or filed and available for testing. Although management indicated incident reports / documentation were completed for the samples selected, the audit was unable to find any documented evidence.

Additionally, there was limited evidence that the policy and work place committees monitor and/or track incidents including monitoring of trends, statistics or number of accidents/incidents.

If incidents are not monitored and reported, health and safety issues may not be addressed in a timely manner which could lead to an unsafe work environment for PS employees.

Recommendations:

4. The Assistant Deputy Minister, Corporate Management Branch, should strengthen the incident reporting process by:
   • Increasing level of awareness and importance of incident reporting in the regions; and,
   • Developing and implementing information management requirements for required documentation when incidents occur.

Annex A: Audit Criteria

Date modified:

2018-01-31