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Audit of Occupational Health and Safety (AU1609)

TABLE OF CONTENTS

EXECUTIVE SUMMARY

INTRODUCTION

By law, the federal government must ensure that all employees are provided with a safe and healthy work environment. The Canada Labour Code – Part II Occupational Health and Safety (CLC Part II) establishes the legislative framework and outlines the duties and responsibilities of both the employer and employees pertaining to occupational health and safety (OHS). The CLC Part II requires that all federal government departments establish health and safety programs to address occupational issues such as accident prevention and investigation, as well as hazards elimination and prevention. The CLC is further supported by the Canada OHS Regulations, the National Joint Council OHS Directive as well as departmental policies and standard operating procedures prescribing specific requirements of duties in the workplace. The establishment of OHS committees and representatives and the provision of training are also fundamental requirements.

The mandate of Natural Resources Canada (NRCan) requires that employees engage in a wide variety of activities which can pose potential occupational health, safety, and security risks. NRCan’s Departmental Occupational Health and Safety Policy highlights that the health and safety of employees is of the utmost importance and commits to providing a safe and healthy working environment for all of its employees; and integrates OHS directives, policies, and procedures into the overall business planning of NRCan.

NRCan conducts research related to Canada’s natural resources sectors in many regional offices across the country. Employees carry out their work duties in different types of work environments: laboratories, field work, offices, and warehouses for storage of specialized equipment. The laboratory and field work environments vary in terms of the activities conducted depending upon the nature of the laboratory and the programs supported. These work environments could potentially expose employees to, for example, chemicals, radiation, sharp tools and equipment, wildlife, difficult meteorological conditions, explosives, and combustible and corrosive materials. Therefore, the laboratory and field work environments have an inherently higher health and safety risk than an office work environment.

The Departmental Occupational Health and Safety Policy recognizes that both employers and employees have joint roles and responsibilities to establish and maintain a healthy and safe work place and are accountable for carrying out defined health and safety responsibilities. The Departmental Occupational Health and Safety Office (DOHS) within the Corporate Management and Services Sector (CMSS) is the functional lead for the Department’s OHS program, while Sectors establish direction and provide support to managers, various OHS committees, and task groups to develop and deliver OHS programs and activities to meet specific requirements within their areas of responsibility.

The objective of the audit was to assess the adequacy of NRCan’s Occupational Health and Safety program. The Audit of Occupational Health and Safety at NRCan was included in the Risk-Based Audit Plan for 2015-2016, in consideration of the inherent health and safety risks to employees working in specialized laboratory ad field work environments. The Risk-Based Audit Plans was approved by the Deputy Minister on March 12, 2015.

STRENGTHS

Overall, the audit found that the Department has a governance structure in place to support the administration of OHS activities. Sectors and regional offices have established solid internal responsibility systems with a focus on employee involvement through the establishment of OHS committees, training, hazard prevention procedures and related occupational health and safety guidance and tools for employees.       

AREAS FOR IMPROVEMENT

The audit identified opportunities for the Department to enhance central guidance and coordination of the OHS program to ensure effective and consistent implementation of OHS prevention programs, and central monitoring and reporting on OHS activities through the DOHS office. In addition, opportunities were identified to update departmental policies, directives and procedures and facilitate greater collaboration and sharing of information and best practices between the various OHS committees, Sectors, and regional offices to minimize duplication of effort and increase efficiency.       

INTERNAL AUDIT CONCLUSION AND OPINION

In my opinion, overall, NRCan has key elements in place to support the Occupational Health and Safety (OHS) program, although the decentralized nature of OHS has an impact on the effectiveness of central coordination resulting in inefficiencies and duplication of effort across the Department. In the absence of central coordination Sectors have implemented several compensating controls including: established OHS committees; developed training, tools and guidance; and, implemented hazard prevention procedures and related occupational health and safety measures. In addition, the lack of central monitoring and reporting mechanisms limits the Department’s ability to identify gaps which could expose NRCan to possible non-compliance issues.

I encourage the Department to continue its efforts in strengthening the OHS program through the development and implementation of the OHS management system and its continued commitment to the health and safety of its staff, contractors, and visitors.

STATEMENT OF CONFORMANCE

In my professional judgement as Chief Audit Executive, the audit conforms with the Internal Auditing Standards for the Government of Canada, as supported by the results of the Quality Assurance and Improvement Program.

Christian Asselin, CPA, CA, CMA, CFE

Chief Audit Executive

June 23, 2016

ACKNOWLEDGEMENTS

The audit team would like to thank those individuals who contributed to this project and particularly employees who provided insights and comments as part of this audit.

INTRODUCTION

In the past 10 years, in both federal and provincial jurisdictions, approximately 1,000 Canadian workers have died each year as a result of workplace accidents or occupational diseases such as falls, accidental contact with a sharp object, tool or machine, or being accidentally struck by an object. Although the injury rate is declining, the annual cost for compensation to injured Canadian workers has amounted to billions of dollars.

By law, the federal government must ensure that all employees are provided with a safe and healthy work environment. The Canada Labour Code – Part II (CLC Part II) establishes the legislative framework and outlines the duties and responsibilities of both the employer and employees pertaining to occupational health and safety (OHS). The CLC is further supported by a number of policies and standard operating procedures prescribing specific requirements of duties in the workplace. The CLC Part II requires that all federal government departments establish health and safety programs to address occupational issues such as accident prevention and investigation, as well as hazards elimination and prevention. The establishment of OHS committees and representatives, and the provision of training are also fundamental requirements.

The mandate of Natural Resources Canada (NRCan) requires that employees engage in a wide variety of activities which can pose potential occupational health, safety and security risks. NRCan’s Departmental Occupational Health and Safety Policy highlights that the health and safety of employees is of the utmost importance and commits to providing a safe and healthy working environment for all of its employees; and integrates OHS directives, policies, and procedures into the overall business planning of NRCan.

NRCan is a medium-sized department employing approximately 4,200 employees (including casual employees and students). The majority of employees work in the National Capital Region; however, there are also employees working in various regions across the country. The diversity of occupational groups employed within the Department reflects NRCan’s dependence on a broad range of skills in science, policy, program administration, and operations. NRCan employees carry out their work duties in different types of work environments: laboratories, field work, offices, and warehouses for storage of specialized equipment.

The laboratory and field work environments vary in terms of the activities conducted depending upon the nature of the laboratory and the programs supported. These work environments could potentially expose employees to, for example, chemicals, radiation, sharp tools and equipment, wildlife, difficult meteorological conditions, explosives, and combustible and corrosive materials. Therefore, the laboratory and field work environments have an inherently higher risk than an office work environment.

The Departmental Occupational Health and Safety Policy recognizes that both employers and employees have joint roles and responsibilities to establish and maintain a healthy and safe work place and are accountable for carrying out defined health and safety responsibilities. The Departmental Occupational Health and Safety Office (DOHS) within the Corporate Management and Services Sector (CMSS) is the functional lead for the Department’s OHS program, while Sectors establish direction and provide support to managers, various OHS committees, and task groups to develop and deliver OHS programs and activities to meet specific requirements within their areas of responsibility.

NRCan senior management, managers, and supervisors have specific OHS duties and responsibilities, which they are required to carry out directly to ensure the safety of staff, visitors, and contractors in their areas of responsibility. OHS committees and Sector OHS Coordinators also have monitoring and oversight responsibilities in addition to the support role they play for management. Employees are expected to follow the OHS procedures established for the workplace and to take precautions that help to ensure their own health and safety as well as that of fellow employees.

During 2014, both the Earth Sciences Sector (ESS) and the Minerals and Metals Sector (MMS) commissioned consulting projects to review their current OHS activities and key gaps. Additionally, in February 2015, a comprehensive and integrated review of NRCan’s OHS management and program, using Canadian Standards Association’s (CSA) Standard Z100-06, Occupational Health and Safety Management System (OHSMS), was commissioned by DOHS and performed by external consultants. 

The Audit of Occupational Health and Safety at NRCan was included in the Risk-Based Audit Plan for 2015-2016, in consideration of the inherent health and safety risks to employees working in specialized laboratory and field work environments. The Risk-Based Audit Plan was approved by the Deputy Minister on March 12, 2015.

AUDIT PURPOSE AND OBJECTIVES

The objective of the audit was to assess the adequacy of NRCan’s Occupational Health and Safety program.

Specifically, the audit assessed whether:

  • An adequate governance framework has been established with respect to occupational health and safety.
  • Adequate OHS operational planning and management processes have been established.
  • An adequate monitoring and reporting framework has been established to ensure that the OHS program is administered in compliance with legal requirements, appropriately responds to any arising issues, and enables decision making.

AUDIT CONSIDERATIONS

A risk-based approach was used in establishing the objective, scope and approach for this audit engagement. A summary of the key underlying areas of risk taken into consideration includes:

  • The governance framework, including documented roles and responsibilities, consistency in managing OHS activities across the Department, and promoting a safe and healthy workplace for NRCan employees may not support the successful delivery of OHS activities;
  • Training, guidance, and tools regarding OHS may not provide stakeholders with the necessary knowledge and skills to understand and fulfill their assigned OHS responsibilities;
  • A Hazard Prevention Program may not be established and monitored to support the appropriate identification and management of OHS risks;
  • Compliance with federal legislation, regulations, directives, and departmental policies may not be monitored to allow the mitigation of potential incidents of occupational injuries and illnesses, and support informed decision making; and,
  • OHS incidents may not be documented and communicated to the delegated authorities in a timely manner to ensure corrective actions are taken as necessary.

SCOPE

The scope of the audit included NRCan’s OHS program, specifically the governance, management and monitoring processes as well as oversight activities for the period of April 2014 to February 2016. The audit also included visits to several regional offices.  The audit did not constitute a technical review of OHS (i.e. handling and storage of hazardous substances, and inspection of tools and equipment).

Given that an audit on physical security, covering the same period, was ongoing by the Audit Branch, any physical security activities (i.e. evacuation plans) were excluded from the scope of this audit. We coordinated with the Physical Security audit team to minimize duplication of efforts wherever possible including interviews, sharing of documents, and coordination of travel. 

APPROACH AND METHODOLOGY

The audit was conducted in accordance with the Treasury Board’s Policy on Internal Audit and Government of Canada Internal Audit Standards and entailed:

  • Reviewing relevant policy instruments and business processes;
  • Reviewing key documents and relevant background information, including previous audit reports relating to occupational health and safety and the three OHS gap analyses performed by external consultants;
  • Conducting interviews and surveys with key personnel and OHS committees;
  • Engaging with and considering relevant audits performed by other federal departments; and,
  • Site visits to local and regional facilities.

The conduct phase of this audit was substantially completed in March 2016.

CRITERIA

The criteria were developed primarily from the Canada Labour Code - Part II. The criteria guided the fieldwork and formed the basis for the overall audit conclusion.

Please refer to Appendix A for the detailed audit criteria.

FINDINGS AND RECOMMENDATIONS

Governance Structure and Monitoring

Summary Finding

The Department has established various Occupational Health and Safety (OHS) committees that provide leadership and demonstrate clear commitment to ensuring that employees are working in a healthy and safe environment. 

With regional offices and laboratories across Canada, the management of occupational health and safety at NRCan is based on centralized oversight by the Departmental Occupational Health and Safety Office (DOHS) and decentralized implementation by the Sectors and regions, resulting in greater accountabilities at the Sector level. A lack of central guidance and coordination has led to ambiguities with regards to the roles of the Departmental Occupational Health and Safety Office, Sector Coordinators and Regional OHS Coordinators respectively.

Furthermore, the decentralized nature of OHS has limited NRCan’s ability to effectively monitor and report key aspects of the department-wide OHS program to senior management, including identifying possible gaps that could lead to situations of non-compliance. In some instances, the Departmental Occupational Health and Safety Office was not made aware of certain information related to OHS activities within the Sectors, such as incident reporting and the appointment of Health and Safety Representatives in certain regional offices.

Supporting Observations

An adequate governance structure allows for management to exercise oversight and enables the achievement of program objectives and priorities. The audit sought to determine: whether the oversight structure meets the requirements of the CLC Part II and related regulations; that there is clarity of roles, responsibilities, and accountabilities; and, that the Departmental Occupational Health and Safety Office (DOHS) provides centralized guidance and coordination of the OHS program. The audit also examined whether an adequate monitoring and reporting framework has been established to ensure that the OHS program is administered in compliance with legal requirements, appropriately responds to arising issues, and enables decision making.

Oversight structure

The Department has established the following committees as required by the CLC Part II and other federal legislation:

  • Policy Committee on Health and Safety (PCOHS) - The departmental oversight committee regarding occupational health and safety, consisting of employee and management representatives from each Sector. The purpose of the committee is to develop and address policy issues related to workplace health and safety; ensure programs are in place for the prevention of hazards; and, provide national leadership, strategic direction, and support to Sector, regional and local committees.
  • Radiation Safety Committee (RSC) - The departmental oversight committee regarding the radiation safety program composed of the Radiation Safety Officer (RSO), a sector senior manager and Site Radiation Safety Officer (SRSO). The RSC considers and advises on the establishment of radiation emergency measures within NRCan facilities, and cooperation and integration with other programs. NRCan conducts research work in several facilities using x-ray equipment, lasers or radioactive material.
  • Workplace Health and Safety Committees (WPHSC) - Committee established in each workplace with more than 20 employees, consisting of employee and management representatives, whose purpose is to resolve safety concerns in the workplace; initiate safer work procedures; serve as a forum for discussing workplace hazards and accidents; and monitor the workplace; and, wherever possible, improve the health and safety of the working environment.
  • Health and Safety representatives - Employees appointed by a collective bargaining agent for each workplace with fewer than 20 employees and responsible for addressing workplace health and safety issues. 

The audit found that the Department’s governance structure is in accordance with the requirements of the CLC Part II and other federal legislation for the establishment of the PCOHS, RSC, and WPHSC.

In addition to the mandatory committees described above, the Department has also established an Occupational Health and Safety Advisory Group (OSHAG), consisting of all Sector and regional health and safety coordinators. The objective of OSHAG is to provide a departmental forum for discussion of horizontal OHS program components; sharing of best practices; and development of OHS programs, procedures, directives, and guidelines for recommendation to senior management and the PCOHS.  The Minerals and Metals Sector (MMS), the Earth Sciences Sector (ESS), and the Canadian Forest Service (CFS) have also established their own OHS committees to provide a Sector forum for sharing best practices and information; raising sectorial OHS issues for discussion and resolution; and guiding the development of each Sector’s respective OHS program, including directives, procedures, and guidelines.

Minutes of committees meetings and results of audit interviews with the various OHS committees indicate that members demonstrate a high level of dedication and commitment to addressing safety issues in the work place; however, the majority of the committees are not operating as per their Terms of References (TOR) or fulfilling their legally required duties. For example, at several PCOHS meetings, non-policy related health and safety issues were being addressed that should have been handled by the respective WPHSC. In addition, it was noted that PCOHS is not monitoring data on accidents, injuries, incidents and health hazards, and the operations of WPHSC, as required by the CLC Part II; instead, Workplace Health and Safety Committees in the regions have been monitoring data on accidents and hazardous occurrences. Another example includes OSHAG, where review of meeting minutes illustrated that there was no sharing of common best practices, and OHS issues arising from Sector and operational activities for discussion and resolution were not being raised.

Collaboration and interaction among various committees is essential for sharing best practices and information, issue identification and resolution, coordinating decision making, and reducing duplication of efforts. The audit found that there is no established relationship between the various OHS committees, resulting in the committees working in isolation. During audit interviews, many committee members stated that they were not aware of the existence and purpose of several of the other committees in place. Review of meeting minutes from various committees confirmed that OHS issues pertaining to Sector or operational activities were not communicated to other oversight bodies.

Roles, responsibilities, and accountabilities

Overall, the audit identified that roles, responsibilities, and accountabilities regarding the management and coordination of the OHS program were not always clearly defined and communicated. The OHS roles, responsibilities, and accountabilities are communicated through various strategic documents, including: committees’ ToRs; the Accountability Framework for Security, Safety, and Emergency Management (SSEM); the Departmental Occupational Health and Safety Policy; and various directives. DOHS has recently developed the NRCan OHS Directive, outlining roles, responsibilities, and accountabilities; however, this directive was in the consultation phase pending approval at the time of the audit. 

According to the Accountability Framework and the Departmental OHS Policy, Sector and Regional OHS Coordinators are responsible for: providing support to managers, safety committees, and H&S representatives in their respective areas; liaising with DOHS; and overseeing and monitoring the implementation of the health and safety program within their areas of responsibility. They also develop programs, guidelines, and procedures to meet specific requirements in their areas of responsibility. Audit interviews confirmed that Regional OHS coordinators have a clear understanding of their roles and responsibilities and are carrying out these specific duties; however, it is unclear as to whether OHS coordinators are administrators or technical advisors. Some OHS coordinators did not always feel comfortable providing technical advice, while other coordinators were technically qualified staff and their specialized advice was invaluable.

Central guidance and coordination of the OHS program

With regional offices and laboratories across Canada, the management of occupational health and safety at NRCan is based on centralized oversight by the Departmental Occupational Health and Safety Office (DOHS) and decentralized implementation by the Sectors and regions, resulting in greater accountabilities at the Sector level. The DOHS is the functional lead for the Department’s OHS program and is responsible for: provision of clear and timely direction on health and safety matters to key players; collaboration with Sectors and regional offices to enable sharing of information and identification of best practices; and formal coordination and monitoring of the OHS program.

As the functional lead for the Department’s OHS program, it was expected that DOHS roles and responsibilities would include the provision of advice on legislative, administrative, and technical health and safety matters; development of the departmental OHS program, including policies, directives, and procedures; and monitoring and reporting internally and externally on the Department’s OHS program performance. Results of audit interviews indicate that DOHS does not have the authority to enforce Sectors to implement tools and programs developed at the departmental level. As a consequence, DOHS has adopted a coordinating role, rather than a key player in establishing, communicating, delivering, and monitoring OHS activities, and this has led to a misalignment of OHS activities across Sectors and the Department.

Coordinators and various committee members also indicated that DOHS has not been providing adequate guidance and tools to enable them to fulfill their responsibilities. For instance, many reported that historically, when DOHS has been asked for technical input, they did not respond in a timely manner, and usually their responses involved an excerpt of the regulations with limited interpretation. There is a lack of collaboration and consultation between DOHS and the Sector and Regional OHS Coordinators to capture best practices and obtain feedback on critical OHS documentation (policies and directives) and tools resulting in diffuse approaches and potential inefficiencies (budgetary and human resources).

Furthermore, the decentralized nature of OHS has limited NRCan’s ability to effectively monitor and report key aspects of the department-wide OHS program to senior management, including identifying possible gaps that could lead to situations of non-compliance. In some instances, the Departmental Occupational Health and Safety Office was not made aware of certain information related to OHS activities within the Sectors, such as incident reporting and the appointment of Health and Safety Representatives in certain regional offices.

Monitoring and reporting

Regular program reporting would support senior management in proactively identifying problem areas for decision making, and monitoring the operating effectiveness of the OHS program and its compliance with legislation. The audit found that current reporting to senior management is limited to: the number of hazardous occurrences, number of WPHSC meetings, and some workplace inspection results at the basic compliance level. The audit noted that no performance measures and indicators had been established, either at the Department or Sector level, to support reporting.

It should be noted that to address this challenge, certain Sectors (MMS and ESS) as well as DOHS have independently developed quarterly dashboards that provide additional relevant OHS information, including: training details, and site inspections and investigations under the radiation safety program. The MMS and departmental OHS dashboards have not been presented to the Sector Management Committee, the Policy Committee of Occupational Health and Safety, or the Executive Committee.

Tracking of hazardous occurrences is accomplished through the Hazardous Occurrence Incident Report (HOIR) in the Health and Safety Program Application (HASPA) centralized database. The HOIR is a comprehensive report that includes a description of the incident, investigation of root causes, and corrective measures taken. Consistency in filling out HOIR is essential to properly identify root causes and recommend appropriate corrective actions; prevent reoccurrence; and enable accurate tracking of trends. Although there is a well-established process for incident reporting and recording that the majority of employees were aware of and generally complied with, review of HOIR sampled from different regional offices illustrated that the HOIR are not documented consistently and that the information provided is not sufficiently detailed. It was noted that in one of the regions sampled, an internal report had been developed and incidents were not being entered in HASPA, while in another region, several hazardous incidents were recorded using the Security Incident Report. Results of audit interviews confirmed that there is a general lack of tracking at all levels to identify trends and preventive/corrective action procedures to address gaps for inadequately controlled hazards.  

Due to HASPA’s limited capacity and a lack of user-friendliness, the application was decommissioned at the end of December 2015 for incident reporting, prior to the implementation of a new system. The Departmental Occupational Health and Safety Office (DOHS) is currently examining the possibility of using the OHS module of PeopleSoft, and implementation of the new process is expected in the fall of 2016. In the meantime, incidents are recorded using the HOIR on InfoForm. Audit interview comments also indicated that the interim incident reporting process was not clearly communicated.

RISK AND IMPACT

Ambiguities in the governance structure and absence of a coordinated corporate OHS function may result in inefficiencies and duplication of efforts across the Department’s Sectors.  In addition, insufficient monitoring and reporting could limit the Department’s ability to identify possible gaps in its OHS program which potentially exposing NRCan to possible non-compliance issues. 

RECOMMENDATIONS

  1. It is recommended that the Director General and Chief Human Resources Officer, in collaboration with sector representatives of the Policy Committee on Occupational Health and Safety, and Sector and Regional OHS Coordinators improve coordination of the NRCan OHS program through:
    1. Clearly defining and communicating the roles, responsibilities and accountabilities of all personnel, specifically key OHS resources; and,
    2. Increased collaboration and consultation with Sector and Regional Coordinators and committee members.
  2. It is recommended that the Director General and Chief Human Resources Officer,  in collaboration with sector representatives of the Policy Committee on Occupational Health and Safety, and Sector and Regional OHS Coordinators, leverage existing best practices to:
    1. Develop a performance measurement framework that ensures consistent and comprehensive periodic reporting to the Policy Committee on Occupational Health and Safety (PCOHS) and the Executive Committee on both the performance and overall effectiveness of the OHS program, and compliance with legislation; and,
    2. Review and revise current hazardous occurrence incident reporting processes for consistency in the identification, assessment and prevention of hazards; and, implementation of a central repository that captures all incidents for comprehensive reporting, as required.

MANAGEMENT RESPONSE AND ACTION PLAN

Management agrees. In response to recommendation 1:

1a. The roles, responsibilities and accountabilities of all personnel, including key OHS resources will be clearly defined and communicated through the updated Departmental Policy on Occupational Health and Safety (OHS) as well as the new Directive on OHS. The OHS Policy, Directive and Management System will establish the overall governance structure of the Departmental OHS Program.

Timing: December 2016 – Draft
March 2017 – Implementation

Sectors to ensure roles and responsibilities of sector OHS committees/groups and programs are clearly defined, established and communicated to DOHS for the inclusion in departmental policies and directives.

Timing: September 2016

1b. Through a clearly established governance structure, leverage existing sector committees/groups and key OHS personnel to increase collaboration and establish mechanisms to improve the flow of information throughout the department.

DOHS and Sectors to further collaborate and share annual OHS work plans to: ensure plans are aligned with departmental initiatives, and to allow DOHS to further assist in supporting Sector requirements.

Timing: March 2017

Management agrees. In response to recommendation 2:

2a. As part of the departmental OHS Management System, a performance measurement and reporting framework will be developed in collaboration with sectors to allow for consistent reporting to PCOHS and EXCom (annually) on legislative requirements, compliance overall effectiveness of the Departmental OHS Program.

The Departmental OHS Dashboard will serve as a monitoring and measurement tool for collecting metrics on both leading and lagging DOHS Management System indicators.

Timing: July 2016 (report on Q1)

Provide an annual update on the Departmental OHS Program to EXCom and seek senior management input.

Timing: April 2017

2b. The OHS Module of PeopleSoft is the central repository for reporting, recording and monitoring all hazardous occurrences and will be fully implemented in NRCan.

PeopleSoft is the Government of Canada Official Standardized People Management System.

Timing: Fall 2016 – Testing

January 1, 2017 – full implementation

Management Processes

Summary Finding

While various policies, directives, and tools have been developed in an effort to provide consistent guidance on occupational health and safety (OHS) across the Department, they are not up-to- date and mechanisms to ensure that key elements of the Department’s OHS programs have not been implemented. 

A comprehensive departmental hazard prevention program has not been finalized for the coordinated and consistent identification, assessment and prevention of risk. In the absence of current central guidance and the provision of centralized tools, Sectors and regional offices have independently developed several compensating controls, including: localized training, Task Hazard Analysis (THA) and workplace inspections. This has resulted in duplication of effort and inefficiencies as each office develops its own procedures and templates.

Furthermore, although training is developed and provided, the Department does not have a mechanism in place to identify training prescribed by legislation or training based on identified needs for employees, managers, committee members and senior management.

In addition, the spectrum of occupational health and safety has historically been focussed on ‘physical’ health and safety, but has recently been expanded to include the concept of psychological or ‘mental’ health. Recent efforts have been initiated at the departmental level to promote awareness; however, opportunities exist to increase the focus on psychological and mental health through Sector and regional OHS committees.

Supporting Observations

The audit sought to determine whether policies, tools, guidance, and training have been developed and implemented to support effective delivery of OHS activities.  The audit also sought to determine whether the Department has established a consistent and systematic risk management approach to identify and prevent health and safety issues, and that there are mechanisms in place to ensure that key elements of the OHS program are implemented.

Health and safety policies, directives, and procedures

A current, robust and comprehensive set of policies, directives, and procedures aligned with legal requirements is essential to provide overall direction to the actions that the Department takes to ensure health and safety in the workplace. NRCan has implemented the Departmental Occupational Health and Safety Policy and various directives related to health and safety; however, the effective dates for these documents vary between January 2004 and March 2010 and audit interviews indicated that they had not been reviewed by the Departmental Occupational Health and Safety Office (DOHS) until recently. Although the policy and directives appear to have been developed consistently with the CLC Part II and related regulations, the audit found that there is no specific methodology by which legal requirements are documented, monitored, and addressed. To address these issues, DOHS is currently updating and streamlining the OHS Policy and related directives with anticipated effective dates starting in April 2016. Furthermore, a Legislative Register identifying Acts, regulations, and other requirements, such as voluntary commitments, having relevance to the various OHS activities has recently been created, but lacks essential information such as effective and revision dates of the Acts and regulations, and evidence of compliance.

Legislation, regulations, and the departmental OHS Policy and directives are listed on the NRCan Occupational Health and Safety Portal, but the audit found that links to many of these documents were not functioning as well as links back to the NRCan OHS Portal from Sectors and regional offices Intranet sites.

The majority of OHS documentation (policies, directives, procedures, etc.) in Sectors and regional offices is kept on internal servers or on their respective health and safety Intranet pages for ease of use and accessibility. A best practice was observed at several CFS regional offices, where all OHS documentation pertaining to these facilities had been amalgamated and organized on their respective Intranet site, including useful links to legislation, policies, procedures, templates, committee meeting minutes, etc.  Furthermore, during site visits to various facilities, it was observed that binders with specific laboratory procedures were included in each laboratory.

Hazard identification, risk management, and preventative measures

Hazard identification and risk assessment is one of the most critical OHS activities for the identification, assessment, mitigation, and monitoring of related risks to reduce employees’ exposure to the risks of injuries, accidents, or illnesses to acceptable levels.  Such components are expected to be outlined in a Hazard Prevention Program (HPP), as required by the CLC Part II and under Section XIX of the Canadian Occupational Health and Safety Regulations.

The audit found that the Department has not yet fully developed and implemented a comprehensive department-wide HPP; however, a draft program document has been prepared by DOSH and consultation with Sectors is expected to take place in the spring of 2016.

In the absence of a formalized hazard prevention program, the identification of hazards associated with specific jobs, tasks, and/or locations has been performed in the regional offices through the use of safe operating procedures and task hazard analysis (THA). A Task Hazard Analysis Directive exists at the departmental level as well as various risk assessment procedures at the Sector and regional levels. The majority of the THAs reviewed by the audit team included a brief description of the task; identification of potential hazards and risks; and control measures to lower the risks; however, they did not always include risk rankings (severity and probability), and prioritization of preventive measures. A best practice was observed in the Earth Sciences Sector’s (ESS) Health and Safety Framework, which includes a very thorough ‘Risk Identification and Management Methodology’ and a template to capture all required information. Given the similarity of tasks performed in various work areas having a specified function or purpose (i.e. laboratories, warehouses, field work, and offices), it was expected that existing THAs would be shared between regional offices and Sectors to avoid duplication of effort and financial costs (i.e. where THAs are developed by external consultants). Results of audit interviews indicated that the Department does not currently have a central repository of identified and assessed hazards.

Potential hazards are also identified through rigorous workplace inspections. As outlined in the CLC Part II, Workplace Health and Safety Committees (WPHSC) and Health and Safety Representatives are required to inspect each month all or part of the workplace, so that every part of the workplace is inspected at least once a year. Although workplace inspections are regularly performed throughout facilities by the WPHSC, numerous methods and forms are used and there is currently no departmental directive on workplace inspection or formal training provided. Audit interviews indicated that the decision for scheduled inspections is not always risk-based, which has resulted in some hazardous laboratories being inspected only once a year.

As a result of hazard identification, preventative and protective measures have been implemented to decrease employees’ risk exposure. The Department adheres to the hierarchy of controls concept of hazard prevention: elimination or substitution, engineering controls, administrative controls such as training and procedures, and personal protective equipment. During site visits, control measures were observed and appeared to be operational, including the use of required personal protective equipment.

Given that many components of the health and safety program are coordinated at the facility level, it was expected that mechanisms would be in place to ensure that all applicable OHS elements and hazards had been identified and addressed. As a best practice, ESS has developed an OHS Program Checklist, which is used for the overall assessment of whether components of the OHS program, some mandated by law, are implemented. For instance, results of audit interviews with DOHS and Sector and Regional OHS Coordinators indicated that several NRCan facilities are being managed by a third party and inspections were not always done within legislated time constraints.

Training and awareness

The provision of employee education and training is an important component of the OHS program as it allows managers, employees, and committee members to fully understand and discharge their responsibilities with respect to OHS under the CLC Part II and other related regulations. The audit noted that employees and managers have been provided various training courses including: Workplace Hazardous Materials Information System (WHIMS); First Aid and CPR; Fire Extinguisher Use; and Awareness of Managers. However, audit interview comments indicated that very few committee members had received formal training or refresher courses, and most had learned by doing and from seeking guidance from their respective Regional OHS Coordinator.

The Department does not currently have a standardized education program in place, identifying training prescribed by legislation or training based on identified needs for employees, managers/supervisors, committee members, and senior management.  Sectors and regional offices have independently developed their own training matrices, resulting in inconsistencies and duplication of effort across the Department, particularly with regards to health and safety orientation for new employees. Several regional offices have developed their own ‘New Employee Orientation Checklists’, requiring employee and supervisor sign-off on specific requirements, including: the knowledge of the Health and Safety Manual; health and safety procedures; task hazard analysis; personal protective equipment; and emergency preparedness.

Tracking training taken by employees, managers/supervisors, and committee members is a critical activity for effective planning and monitoring, and ensuring that employees’ certifications remain current. The methodology for tracking training varied between and within Sectors, ranging from an Integrated Staff Management System, in one instance, to excel spreadsheets in another.  It was also observed that there was a lack of awareness regarding ownership of training records, and these were being maintained either with the Health and Safety Coordinator, in Human Resources (HR) or with the laboratory supervisor.  Inconsistency in tracking of training taken makes it difficult for the department to monitor and report on its training program which could lead to inaccurate and incomplete information for decision-making.

The audit noted that to address these challenges, the Departmental Occupational Health and Safety Office (DOHS) has created the ‘NRCan OHS Training Requirements’, which identify generic mandatory training for employees, managers/supervisors, and executives. In addition, a working group, consisting of Sector and Regional Health and Safety Coordinators, has developed a departmental OHS Training Profile Builder. This tool provides queries about the employees’ activities, which are input into an Excel spreadsheet, and training needs are computer-generated based on the responses. This profile builder will also be used for identifying training needs for committee members, Health and Safety Representatives, Building Emergency Operations, and the Emergency Response Team. DOHS is also currently looking into using PeopleSoft to address the issue of inconsistent tracking of training taken across the Department. Although several initiatives have been taken by DOHS to address the various training issues, they have yet to be approved and implemented.

Psychological Health

The spectrum of occupational health and safety has historically been focussed on ‘physical’ health and safety, but has recently been expanded to include the concept of psychological or ‘mental’ health. Recent efforts in this area have been made at the departmental level, with the appointment of an NRCan Champion for Mental Health, and revival of the Fitness and Wellness Committee (a forum where Sector representative consider employee wellness initiatives).

OHS governance bodies have, to date, had a limited focus on psychological health. Review of committees’ meeting minutes confirmed that psychological health is not addressed at meetings and audit interview comments illustrated that many members had not given any consideration to addressing psychological health as part of their roles and responsibilities, but agree that it should be a recurring item on their agendas. The Earth Sciences Sector (ESS) has taken the lead in commissioning an analysis of the Sector’s psychological health and safety management system. The audit also noted that recent efforts have been made in regional offices to create awareness, including lunch and learn sessions on topics such as stress management and work-life balance. In the Twenty-Second Annual Report to the Prime Minister on the Public Service of Canada dated March 31, 2015, the Clerk of the Privy Council indicated that increasing awareness and removing the stigma surrounding mental health issues is essential to supporting a healthy and safe work environment.

RISK AND IMPACT

Absence of a current, robust and comprehensive set of OHS policies, directives, and procedures aligned with legal requirements may result in a lack of overall direction and support for the governance structure of the OHS program. Moreover, the lack of a formalized department-wide Hazard Prevention Program (HPP) and comprehensive tools to ensure components of the OHS program are established, may result in inconsistencies in hazards identification, assessment and control and may expose the Department to potential non-compliance risks. Where training needs are not assessed and tracked consistently across the Department, there is a risk that employees and committee members are not receiving sufficient and timely training to enable them in discharging their OHS responsibilities.

RECOMMENDATIONS

  1. It is recommended that the Director General and Chief Human Resources Officer, in consultation with sector representatives of the Policy Committee on Occupational Health and Safety, and Sector and Regional OHS Coordinators, leverage existing best practices to:
    1. Review, update, and streamline the Departmental Occupational Health and Safety Policy and the various directives;  
    2. Review and update the Legislative Register to include the effective and revision dates of the Acts and regulations, and demonstration of departmental compliance; and,    
    3. Develop and implement mechanisms and comprehensive tools to ensure that all components of the OHS program are implemented and consistent with the requirements of applicable legislation and related regulations.
  2. It is recommended that the Director General and Chief Human Resources Officer, in collaboration with sector representatives of the Policy Committee on Occupational Health and Safety, and Sector and Regional OHS Coordinators, leverage existing best practices to:
    1. Develop and implement a more comprehensive department-wide hazard prevention program to fully support legal requirements, including leveraging from existing best practices within Sectors; and,
    2. Develop and implement a common approach to identifying training needs and track training taken by OHS committee members, health and safety representatives and departmental employees to ensure they receive training in health and safety, as required by CLC Part II.
  3. It is recommended that the Director General and Chief Human Resources Officer develop guidance and tools to promote greater awareness across the department on mental health through existing OHS committees’ or other relevant committees, as appropriate.

MANAGEMENT RESPONSE AND ACTION PLAN

Management agrees. In response to recommendation 3:

3a.  As per 1a., the Departmental Occupational Health and Safety Policy and OHS Directive are currently being updated and developed to standardize and streamline roles, responsibilities and accountabilities to ensure consistent guidance on OHS across the Department.

Timing: December 2016 – Draft

March 2017 – Implementation

Other OHS directives are being reviewed and updated, or converted to procedures where needed; drafts will be shared with PCOHS and sectors for review and consultation prior to implementation.

Timing: March 2018

3b. A draft Legal Register has been developed (as recommended in the Gap Analysis conducted in 2015), to identify OHS legal requirements and will be included in the Occupational Health Management System. DOHS will seek sector input and PCOHS endorsement prior to implementation.

Timing: December 2016

3c. A comprehensive OHS Management System and Framework consisting of the OHS Policy, Directive and SOPs, including various tools is being developed to support the implementation of the overall OHS program consistent with the requirements of applicable legislation and related regulations.

Timing: March 2017 – draft
(full implementation of the OHSMS March 2019)

Management agrees. In response to recommendation 4:

4a.  DOHS will leverage existing best practices within sectors and share a draft of the Hazard Prevention Program (HPP) with sectors and key OHS personnel for input, and subsequently present the HPP to PCOHS for endorsement.

Timing: October 2016 - Draft

Sectors to implement the HPP in their respective areas (develop critical task inventories, conduct risk assessments, task hazard analyze, develop safe work practices, provide training etc.).

Timing: March 2019 (3-yr implementation) Sectors to include HPP in their annual work plans.

4b. DOHS engaged external expertise to conduct a review of the Department’s current training program in efforts to standardize training and establish a centralized tracking system and training tools.

DOHS, in collaboration with sectors OHS Advisors, leveraged existing tools and best practices to further develop a suite of training tools to assist sectors in meeting their training requirements (listing of mandatory training requirements, a training needs assessment tool, access to online OHS courses and a course listing. Sectors have established mechanisms and tools to meet sector requirements.

The Enterprise Learning Module of PeopleSoft is the departmental central repository to identify, record, track and monitor training requirements to ensure compliance with legislation.

Sectors are required to ensure all training data is recorded and centralized within PeopleSoft to allow DOHS to effectively monitor, measure and report on the performance of the departmental OHS training program.

Timing: September 2016 – current version 8.9
Version 9.1 – TBD

Management agrees. In response to recommendation 5, the Values and Ethics, and Workplace Wellness Unit (VEWW) is developing a departmental Strategy on Mental Health and Wellness in the Workplace to address psychological health and safety in the workplace. DOHS and ESS are working with VEWW on this initiative. The draft Strategy will be implemented based on the following pillars over the next three years:

  • Implementation of the National Standard on Psychological Health and Safety in the Workplace;
  • Raise awareness and understanding of mental health issue and importance of intervention;
  • Build supportive mechanisms for positive mental healthFootnote 1 and wellness;
  • NRCan has established Champions for Mental Health, and for Fitness and Well-Being who are responsible for promoting departmental programs and raising awareness around mental health and fitness and well-being.  Communications from Champions already; and
  • In addition, NRCan has already secured the offering of a Mental Health Leadership Certificate to employees in “first responder” positions such as OHS, LR, Security. The certificate was completed by approximately 25 employees.

Timing: 3-yr implementation plan
completed by March 2019

APPENDIX A – AUDIT CRITERIA

The criteria were developed primarily from the Canada Labour Code – Part II. The criteria guided the fieldwork and formed the basis of the overall audit conclusion.

The objective of the audit was to assess the adequacy of the NRCan Occupational Health and Safety program.

The following audit criteria were used to conduct the audit:

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