Audit of Occupational Health and Safety

Acronyms and Symbols

CLC

Canada Labour Code

COHSR

Canadian Occupational Health and Safety Regulations

HCM

Human Resources Branch

HPP

Hazard Prevention Program

HPPOT

HPP Online Tool

HSMS

Health and Safety Management System

HWD

Workplace Relations and Corporate Health Bureau

HWH

Corporate Health Programs Division

ISO

International Organization for Standardization

OHS

Occupational Health and Safety

OHSCOT

OHS Committee Online Tool

ZIB

Values, Ethics and Workplace Well-being Division

Executive Summary

In accordance with Global Affairs Canada’s approved 2018-2019 Risk-based Audit Plan, the Office of the Chief Audit Executive conducted an Audit of Occupational Health and Safety (OHS).

Why it is important

Global Affairs Canada has the legal obligation, as outlined in the Canada Labour Code, Part II, to protect the health, safety and well-being of its employees while at work. These obligations extend to workplaces located in the National Capital Region, five Canadian regional offices, and 178 missions abroad. Meeting these obligations is rendered more complex given that almost 50% of employees are located outside of Canada.

What was examined

The objective of the audit was to provide reasonable assurance that Global Affairs Canada has an effective occupational health and safety management system in place to ensure compliance with the Canada Labour Code, Part II as well as other applicable policies and legislation.

The audit covered the period from April 2017 to January 2019. The audit team assessed the Department’s current OHS practices, procedures, processes and systems in place at workplaces in Canada and abroad, and included visits to workplaces at headquarters and four missions. In addition, as sound mental health and well-being of employees play a role in fostering a safe workplace, the audit reviewed the status of the development of a departmental strategy on mental health, as mandated by the Federal Public Service Workplace Mental Health Strategy.

The audit did not include OHS elements related to the physical aspects of security and real property infrastructure as this area was previously covered by other audit work. In addition, the audit did not constitute a technical review of occupational health and safety on a site-by-site basis. Further, the audit did not include a review of the incident in Havana, Cuba as there is an ongoing legal case.

What was found

Global Affairs Canada has key elements of an occupational health and safety management system in place such as an internal responsibility system, strategic objectives, training, safety-related committees as well as a Hazard Prevention Program. However, certain aspects require significant improvement to ensure greater compliance with safety regulations. OHS-related roles and responsibilities were established in different functional areas within the Department. In addition, strategic objectives for the OHS program were developed, but there was no fully-resourced operational plan taking into consideration the risk exposure to the Department. Such a plan could help to prioritize the numerous legal requirements of an OHS program.

Various forms and means of safety-related training were available, but required training was not monitored for completion to ensure all employees were aware of their responsibilities and acted in a manner to mitigate risks in their workplaces. The required safety-related committees were in place; however, compliance of workplace safety committees was low. A newly implemented OHS Committee Online Tool (OHSCOT) should facilitate the oversight of these safety-related committees and foster greater compliance. In addition, a Hazard Prevention Program Online Tool (HPPOT) was in place to identify the required training for employees as a result of hazards in their workplaces. Although hazardous risks have been identified at a departmental level, no comprehensive program was developed to address each identified hazard using a risk-based approach. The audit found that a draft Department-specific mental health strategy has been developed in alignment with the federal strategy. Further, it was found that the development of performance indicators, and greater monitoring and reporting of the OHS program were required to support decision-making.

Recommendations

1. The Assistant Deputy Minister of Human Resources (HCM) should develop a fully-resourced operational plan relating to the OHS program taking into consideration the risk exposure to the Department to achieve strategic objectives.
2. The Assistant Deputy Minister of Human Resources (HCM) should monitor the completion of required safety-related training by all employees.
3. The Assistant Deputy Minister of Human Resources (HCM) should develop a comprehensive program for each identified departmental hazard as part of the Hazard Prevention Program using a risk-based approach.
4. The Assistant Deputy Minister of Human Resources (HCM) should develop performance indicators for the OHS program, monitor compliance with relevant OHS regulations, and formally report accordingly.

Statement of Conformance

In my professional judgment as the Chief Audit Executive, this audit was conducted in conformance with the Institute of Internal Auditors' International Standards for the Professional Practice of Internal Auditing and with the Treasury Board Policy and Directive on Internal Audit, as supported by the results of the quality assurance and improvement program. Sufficient and appropriate audit procedures were conducted, and evidence gathered, to support the accuracy of the findings and conclusion in this report, and to provide an audit level of assurance. The findings and conclusion are based on a comparison of the conditions, as they existed at the time, against pre-established audit criteria that were agreed upon with management and are only applicable to the entity examined and for the scope and time period covered by the audit.

1. Background

The Audit of Occupational Health and Safety was identified as part of the Global Affairs Canada 2018-20 Risk-based Audit Plan, which was recommended by the Departmental Audit Committee and approved by the Deputy Minister on April 30, 2018.

Global Affairs Canada has a legal obligation to protect the health, safety and well-being of its employees while at work. These obligations are principally regulated by Part II of the Canada Labour Code (CLC) and Canada Occupational Health and Safety Regulations (COHSR) which apply to employees and other persons who perform work for the federal public service. This legal framework establishes a number of rights and obligations for the department, managers, employees and committees, the purpose of which is “to prevent accidents and injury to health arising out of, linked with or occurring in the course of employment.” Preventive measures include the reduction or elimination of hazards, and the provision of personal protective equipment, clothing, devices or materials. On October 25, 2018, an act to amend the CLC, Part II to further protect federal employees from harassment and violence in the workplace received Royal Assent and will result in a revised CLC, Part II.

The Department must meet the requirements of other legislation, directives, standards and guidelines which aim to enhance the CLC, Part II or guide employers in its implementation. The key ones are the following:

• Treasury Board Policy on Occupational Safety and Health: The objective is to promote a safe and healthy workplace for Public Service employees as well as reduce the incidence of work-related injuries and illnesses.
• The National Joint Council Occupational Health and Safety Directive: This directive is an amalgamation of all occupational health and safety (OHS) directives and includes the minimum standards that should be met by an employer’s OHS program.
• Canadian Standards Association has developed technical health and safety standards from recognized best practices.
• Employment and Social Development Canada has oversight of government safety programs to promote and sustain safe workplaces under federal jurisdiction. Through the statutory powers of their health and safety officers, inspections of workplaces and safety audits may be conducted, directions to an employer may be issued, and prosecutions may be initiated when non-compliance continues.

In addition, the Federal Public Service Workplace Mental Health Strategy requires federal organizations to develop a comprehensive strategy on mental health that is unique to their organization.

Departmental Context

The OHS environment at Global Affairs Canada is complex, encompassing multiple sites in the National Capital Region, five Canadian regional offices, and Canada’s network of 178 missions in 110 countries around the world. The Department is responsible to protect the health and safety of over 10,000 employees, as well as employees of partners (e.g. federal departments, agencies) and co-locators (e.g. Crown corporations, provincial governments and other national governments), working in departmental workplaces around the world.

2. Observations and Recommendations

It was expected that the Department would have an overarching framework to meet its OHS legislative requirements. Such frameworks, referred to as a Health and Safety Management Systems (HSMS), have been developed by the Canada Standards Association and the International Organization for Standardization (ISO) and have been recognized as an industry best practice. This framework allows a systematic and preventive approach to OHS and comprises key elements, each of which is described below.

This section sets out findings and observations, divided into the key elements of an HSMS examined as part of the scope of this audit: internal responsibility system; strategic objectives; training; safety-related committees; hazard prevention program; and performance indicators, monitoring and reporting.

2.1 Internal Responsibility System

An internal responsibility system sets the roles and responsibilities of the employer, workers, health and safety officers, and health and safety committees. It was expected that the Department would have a clear reporting structure related to the OHS program to ensure its compliance with CLC, Part II requirements. The audit team found that roles and responsibilities have been established among the different functional areas within the Department.

The audit team found an OHS Statement signed by the Deputy Minister of Foreign Affairs confirming the Department’s commitment to meeting the obligations of CLC, Part II. Reporting to this Deputy Minister, the ADM of Human Resources (HCM) is accountable for the Department’s OHS function. This responsibility is delegated to the Workplace Relations and Corporate Health Bureau (HWD) that manages the OHS program within the Corporate Health Programs Division (HWH) comprising a Director and four officer positions, one of which is vacant. This program covers a wide-range of OHS-related areas such as operations management, workplace violence prevention, hazard prevention, and includes overseeing OHS committees in domestic and international workplaces. The program is also responsible to track and report injuries and accidents which occur in the workplace.

The Values, Ethics and Workplace Well-being Division (ZIB) is responsible for the management of the Employee Assistance Program, Informal Conflict Management System, Values and Ethics and Corporate Well-being. As part of these functions, this division is the lead on the establishment of a departmental Mental Health Strategy. As mental health is an important aspect of overall OHS, the Corporate Health Programs Division and the Values, Ethics and Workplace Well-being Division collaborate on cross-cutting issues.

At missions, the Heads of Mission are responsible for ensuring that an effective local OHS program is in place including the establishment and monitoring of an OHS workplace committee.

The audit team reviewed the accountability surrounding the OHS program and found an appropriate reporting structure in place.

2.2 Strategic Objectives

It was expected that strategic objectives would be in place to ensure the Department could meet its legal OHS obligations. Although strategic objectives were developed, they were not supported by an operational plan.

Strategic objectives and outcomes were developed by the Corporate Health Division. These objectives took into consideration known regulatory shortfalls and included high level target dates for their achievement. However, there was no accompanying plan to operationalize these objectives taking into consideration the resources available in the Corporate Health Programs Division and the Department’s exposure to risk. Such a plan could help to prioritize the numerous legal obligations of an OHS program. Without such an operational plan, senior management cannot assess the status of expected outcomes and whether an appropriate amount of human and financial resources has been allocated to meet priorities within set timelines.

Recommendation

1. The Assistant Deputy Minister of Human Resources (HCM) should develop a fully-resourced operational plan relating to the OHS program taking into consideration the risk exposure to the Department to achieve strategic objectives.

2.3 Training

According to CLC, Part II and COHSR, proper training in OHS matters should be provided to employees including to those with supervisory responsibilities and members of safety-related committees. The audit team reviewed the OHS training material, and found that although various training mediums and sources were available to employees, completion of required training was not monitored.

Various types of OHS training were found to be available online as well as in a classroom setting through the departmental intranet, internet, internal trainers as well as external service providers. As per CLC, Part II, certain training to all employees is mandatory such as “Basics of Health and Safety, Workplace Hazardous Material Information System and First Aid.” Although these courses were available through the Department, they were not monitored for completion.

Through the Hazard Prevention Program (HPP) Online Tool (HPPOT), supervisors completed a job hazard assessment form to identify potential hazards for their employees. As a result, training relevant to employees’ job-related duties and environment was identified. For the majority of employees who had office-type of jobs, the obligatory training comprised short “You Tube” videos available on the intranet. For employees in high risk positions, videos and training material, such as “Confined Space, Driving a Vehicle, Use of Ladders/Scaffolding and Lifting Devices”, were available on the Corporate Health Programs Division’s intranet site, Safety Care Training Hub. However, to obtain certification for certain types of high risk activities, additional practical training would be necessary. In addition, there was no post-session testing to verify understanding and competence. The Corporate Health Programs Division did not monitor the completion of both job hazard assessments by supervisors and training by employees.

For supervisors, specific training, “Occupational Health and Safety and Hazard Prevention Workshop for Managers,” was available. Interviews with safety committee members indicated that they were aware of relevant training available on the departmental intranet. They expressed their commitment in completing the training and informing new members upon joining. However, there was no monitoring of the completion of this recommended training for supervisors and committee members.

Since there was no monitoring of the completion of required training, senior management cannot assess whether supervisors and members of safety-related committees are fully aware of their OHS responsibilities and whether employees have the knowledge to fulfill their duties in a safe manner to mitigate risks in their workplaces.

Recommendation

2. The Assistant Deputy Minister of Human Resources (HCM) should monitor the completion of required safety-related training by all employees.

2.4 Occupational Health and Safety Committees

It was expected that the Department would have put in place the required safety committees to support management in fulfilling its safety responsibilities and help ensure the effective delivery of the OHS program in accordance with OHS regulations. The audit team reviewed the safety-related committee structure and found that the Department had established the required OHS committees; however, compliance requirements were not met by all of the workplace safety committees.

OHS Policy Committee

The CLC, Part II requires employers under federal jurisdiction with more than 300 employees to have an OHS Policy Committee in place, with the core responsibilities to participate in the development of health and safety policies and programs; participate in the development and monitoring of a program for the prevention of hazards in the workplace that also provides for the education of employees in health and safety matters; and monitor data on work accidents, injuries and health hazards.

It was noted that the Department has an OHS Policy Committee that is co-chaired by two representatives, one from management and the other from a bargaining unit, as required. The Terms of Reference for the OHS Policy Committee is in compliance with the above requirements and included additional responsibilities to provide advice to senior management on OHS matters affecting Global Affairs Canada employees. Based on a review of a sample of minutes from 2017 and 2018, regular meetings took place. In addition, it was noted that the OHS Policy Committee had discussions about OHS matters such as asbestos, air quality and first aid requirements. Further, in consultation with the Corporate Health Programs Division, the OHS Policy Committee developed a set of priorities intended to improve compliance over a two-year period.

Workplace Safety Committees

The CLC, Part II requires all departments to have workplace safety committees in place at all facilities that have more than 20 employees and a designated OHS representative in workplaces where there are fewer than 20 employees. In addition, it is required that these committees meet a minimum of nine times per year, conduct yearly workplace hazard inspections, ensure adequate records of accidents and incidents, and work to resolve OHS issues brought to their attention.

The audit team noted that 109 workplace safety committees were in place domestically and internationally as these workplaces had more than 20 employees. According to the Department’s 2017 Local Committee Report and May 2018 Employer Annual Report Statistics, only 28 of 109 workplace safety committees fulfilled the requirement to meet nine times per year. There was limited oversight by the Corporate Health Programs Division of these committees with regards to satisfying compliance requirements. As mentioned later in this report, the OHS Committee Online Tool (OHSCOT) launched in January 2019 is intended to address this gap. By not fulfilling their responsibilities, workplace safety committees may not be contributing to the mitigation of risk exposure to workplace hazards.

2.5 Hazard Prevention Program

Hazard Prevention Program Overview

The COHSR, Part XIX requires employers to develop, implement and monitor a program for the prevention of hazards. Therefore, it was expected that the Department would have developed a Hazard Prevention Program (HPP) comprising an implementation plan, a methodology to identify and assess hazards, preventive measures, employee education, and periodic program evaluations. The audit team reviewed the Department’s program for the prevention of hazards and found that some improvements were needed.

In 2013, a review of the Department’s HPP was conducted by an external health and safety organization. Based on this assessment, it was found that many elements were partially compliant with requirements of the HPP regulation. Another key finding was that the process for hazard identification and risk assessment required refinement and formalization. In addition, this assessment found that greater organizational commitment, competency and capacity were needed to establish, implement and monitor a successful HPP. The audit team observed that some of the deficiencies identified in 2013 still exist.

The audit team found certain components of an HPP were in place. There were some safe work practices and procedures about protection and equipment operations on Modus that were related to identified risks such as lifting heavy loads and the use of power tools and ladders. As well, the Corporate Health Programs Division was providing advice to stakeholders leading the resolution of identified hazards such as air quality and asbestos as per the OHS Policy Committee’s presentation to the Corporate Management Committee in June 2018. Additionally, an HPP Online Tool (HPPOT) was in place allowing supervisors to identify potential hazards for their employees, complete the required job hazard assessment forms, and identify required training.

As part of a formal HPP, the Corporate Health Programs Division has taken an initial step of identifying hazards (e.g. physical, chemical, biological, ergonomic, environmental, physiological, emergency and threats) for the department as a whole. However, for each of these identified hazards, (e.g. Workplace Hazardous Material Information System, First Aid, confined spaces, and fire safety and emergency response) a comprehensive program comprising defined roles and responsibilities, training and record keeping in compliance with relevant directives and guidelines had not been developed. Given the numerous identified hazards, the development of a program for each hazard would be feasible using a risk-based approach.

All accidents, occupational diseases and hazardous occurrences must be investigated, recorded and reported by the employer. Procedures on how to conduct an investigation were noted on the departmental intranet. The audit team reviewed a sample of investigation reports from 2017 to 2018. It was found that the reports were completed by a manager and a health and safety representative or committee representative as per ESDC requirements. In addition, departmental security officers were involved in investigations when required. However, the audit team found that the information from these reports was not used as a learning tool to identify root causes, mitigate future occurrences and improve processes.

The audit team reviewed one example of a requirement under the COHSR, Part XVII which requires every employer to have an emergency response plan with prescribed standards, procedures and training relating to all emergencies. At missions, emergency plans have evolved into an “all hazards” plan. Based on a review of a sample of plans and site visits to missions, the audit team confirmed that security officers took the lead on developing emergency plans and organizing safety-related drills and evacuation simulations. At headquarters, emergency response was the responsibility of the Departmental Security Officer, as expected. The audit team found that as per COHSR regulations, the Corporate Health Programs Division did not have a Fire Safety and Emergency Measures Program in place documenting the respective roles of the Corporate Health Programs Division and security officers.

The audit team found no implementation plan to support the OHS program’s strategic objectives in order to address the recognized, long-standing deficiencies in the HPP. Without a fully developed and implemented HPP, the Department is unable to have a coordinated and consistent approach to identification, assessment and mitigation of hazards to reduce employees’ exposure to the risk of injuries, accidents and illnesses.

Mental Health Hazards

In accordance with the CLC, Part II and the Canadian Standards Association, safety officers are the lead in identifying, assessing and controlling mental health risks from a safety perspective. The audit team found that the Corporate Health Programs Division developed and put in place procedures and tools for identifying, assessing and controlling some mental health risks. These included tools available on the departmental intranet related to the awareness of psychological health in the workplace, post-traumatic stress disorder, and violence in the workplace. However, the audit team did not find a related mental health hazard program in place which requires defined roles and responsibilities, and training in compliance with relevant safety regulations and directives. Consequently, this may result in a delayed response to employees in need.

Mental Health Strategy

The Federal Public Service Workplace Mental Health Strategy requires federal organizations to develop their own comprehensive and unique strategies on mental health in order to achieve organization-wide healthy workplace objectives. The federal strategy looks to align to the National Standard of Canada for Psychological Health and Safety in the Workplace, which identifies 13 factors that contribute to poor workplace psychological health, including items such as unfair treatment, excessive workload, unfulfilling work, lack of professional development, violence, harassment, poor physical work environment and lack of accommodation.

It was expected that the Values, Ethics and Workplace Well-being Division, as the lead on mental health, would develop a Department-specific mental health strategy in accordance with the national strategy. Based on the audit team’s review of the draft strategy, five of the recognized 13 factors were addressed as priorities within the department. While the roll-out of the strategy remained to be finalized and approved, it did not identify the following recognized safety considerations: protection from violence, bullying and harassment, or protection for physical safety. As these areas fall under the program responsibility of the Corporate Health Programs Division as well as other units in the department, consolidated input would be required to eventually integrate into the draft strategy.

The audit team found parallel activities being undertaken by the Corporate Health Programs Division and the Values, Ethics and Workplace Well-being Division. Based on audit interviews and documentation review, work was noted to being done in a coordinated and integrated manner between the two stakeholders.

Recommendation

3. The Assistant Deputy Minister of Human Resources (HCM) should develop a comprehensive program for each identified departmental hazard as part of the Hazard Prevention Program using a risk-based approach

2.6 Performance Indicators, Monitoring and Reporting

It was expected that performance indicators would have been developed to monitor critical OHS program elements to ensure compliance with legal requirements and that this information would be reported to the senior executive representing the employer. The audit team found that there were no indicators to monitor the performance of the OHS program and limited reporting took place.

The audit team found no performance indicators prepared for the OHS program. Therefore, no monitoring against these indicators could take place to ensure compliance with relevant OHS regulations. Consequently, there was limited performance information available to report to various levels within the Department. For example, the OHS Policy Committee reported to the Corporate Management Committee annually as required by their mandate. In its most recent reporting in June 2018, the OHS Policy Committee presented its priorities including a progress update on subsequent steps over a two-year period. However, there was limited information presented on the performance of the OHS program. Therefore, senior management, including the senior executive representing the employer, may not be aware of critical OHS deficiencies to assess whether corrective actions need to be taken.

An annual report providing health and safety statistics on reported hazardous occurrences was prepared by the Corporate Health Programs Division and submitted to Employment and Social Development Canada and the OHS Policy Committee. These reports were at a high level with little detail related to the context and cause of incidents which could have helped to identify trends and to continually improve processes. In 2017, the Corporate Health Programs Division reported that OHS workplace safety committees recorded a total of 111 injuries and incidents. The Corporate Health Programs Division indicated that this occurrence rate seemed low given the more than 10,000 employees and the various risk environments in which the Department operates. The lack of key performance indicators and incomplete reporting on hazard occurrences limit the ability of senior management to measure the state of compliance with legal and policy OHS requirements and make required adjustments to the OHS program.

Being aware of gaps in monitoring and reporting, the Corporate Health Programs Division launched the OHS Committee Online Tool (OHSCOT) in January 2019. The purpose of the tool is to ensure safety-related committees meet their mandatory requirements, such as the preparation of specific reports, the number of meetings per year, facility inspections, member composition and training. In addition, it includes standardized templates such as for meeting agendas and minutes. Further, this tool serves as a central database that is accessible by members from all committees and it can generate statistical reports and dashboards. Based on the audit team’s review, this tool can facilitate the Corporate Health Programs Division’s oversight of compliance and prompt follow-ups with committees not meeting their obligations.

Additionally, the Corporate Health Programs Division is awaiting approval for the funding of additional staff to support the administration, coordination, guidance and training of committee members and technical support of the OHS Committee Online Tool (OHSCOT) and the HPP Online Tool (HPPOT). These additions will increase the Corporate Health Programs Division’s capacity to support OHS program activities.

Recommendation

4. The Assistant Deputy Minister of Human Resources (HCM) should develop performance indicators for the OHS program, monitor compliance with relevant OHS regulations, and formally report accordingly.

3. Conclusion

Global Affairs Canada has key elements of an occupational health and safety management system such as an internal responsibility system, strategic objectives, training, safety-related committees as well as a Hazard Prevention Program. However, some deficiencies have been long-standing particularly for certain aspects of the OHS program that require significant improvement to ensure greater compliance to OHS regulations.

Appendix A: About the Audit

Objective

The objective of this audit was to provide reasonable assurance that Global Affairs Canada has an effective occupational health and safety management system in place to ensure compliance with the Canada Labour Code – Part II as well as other applicable policies and legislation.

Scope

The audit examined the Department’s OHS practices, procedures and processes for the period from April 2017 to January 2019. The audit covered all workplaces domestically and internationally and included visits to workplaces at headquarters and four missions. In addition, as sound mental health and well-being of employees play a role in fostering a safe workplace, the audit reviewed the status of the development of a departmental strategy on mental health, as mandated by the Federal Public Service Workplace Mental Health Strategy. The development of this strategy was led by the Values, Ethics and Workplace Well-being Division.

The audit did not include OHS elements related to the physical aspects of security and real property infrastructure as this area was covered in the 2018 Audit of Physical Security conducted by the Office of the Chief Audit Executive (VBD). In addition, the audit did not constitute a technical review of occupational health and safety on a site-by-site basis (e.g. the handling and storage of hazardous substances and inspections of tools and equipment). Further, the audit did not include a review of the incident in Havana, Cuba as there is an ongoing legal case.

Criteria

The following criteria were developed based on a detailed risk assessment:

1. The Department has a clear governance structure in place for managing OHS, outlining roles, responsibilities, accountabilities, authority and decision-making.
2. The Department identifies, assesses and addresses risks in accordance with the Canada Labour Code and other regulatory and policy requirements.
3. Appropriate OHS training activities are established and delivered.
4. The Department adequately monitors and reports comprehensively on OHS activities to oversight bodies.

Approach and Methodology

In order to conclude on the above criteria, the following methods were used to gather evidence and test compliance against key CLC, Part II and COHSR requirements:

• Identification and review of safety management manuals and documents;
• Review of other relevant documentation;
• Crosswalk of safety-related procedures to documentation provided;
• Review of the functioning of the OHS Policy Committee and workplace safety committees at headquarters (125 Sussex Drive, 111 Sussex Drive, 200 Promenade du Portage) and missions (Addis Ababa, Bogota, Guatemala City, Pretoria);
• Walkthroughs of online safety tools;
• Review of a sample of hazardous occurrence investigations; and
• Interviews of relevant departmental personnel.

Appendix B: Management Action Plan