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Internal Audit Report
September 2009
Table of Contents
- Executive Summary
- Introduction
- Audit Opinion
- Findings, Recommendations and Management Action Plan
- Appendix A: Roles and Responsibilities
- Appendix B: Audit Criteria
- Appendix C: List of Acronyms
Executive Summary
Background
It is the policy of the federal government to ensure all employees are provided with a safe and healthy work environment. The Canada Labour Code (CLC) Part II establishes the legislative framework and outlines the duties and responsibilities of the employer and employees pertaining to occupational health and safety (OHS). Each duty outlined in the CLC Part II has a corresponding regulation prescribing specific requirements.
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, hazards elimination and prevention. The establishment of workplace health and safety committees and the provision of training are also fundamental requirements.
The Canada Border Services Agency's (CBSA) OHS function has not been the subject of a formal departmental internal audit since the Agency's creation in December 2003. Given the importance of this function in the workplace, an audit was included in the Three-year Risk-based Audit Plan for fiscal year 2008/09–2010/11.
Objective and Scope
The audit objective was to provide assurance on the effectiveness of the Agency's OHS Management Control Framework to promote compliance with the requirements of the CLC Part II and its regulations. The fieldwork was conducted between February and April 2009 and the scope focused on activities from January 1, 2007 to March 31, 2009.
Statement of Assurance
This audit engagement was planned and conducted in accordance with the Internal Auditing Standards for the Government of Canada.
Audit Opinion
The Agency had a governance structure in place and implemented a number of programs and initiatives based upon risks to promote a healthy and safe workplace. The Management Control Framework for the Occupational Health and Safety Program was partially effective to ensure compliance with mandatory requirements of the CLC Part II and its regulations. Opportunities exist to strengthen the framework in the areas of accountabilities, responsibilities, planning, and program monitoring.
Main Observations
The organizational and governance structures were established to administer and oversee OHS activities. Overall guidance was provided by the Policy Health and Safety Committee. The members of workplace committees and health and safety representatives demonstrated a high level of dedication in addressing safety issues. The Agency developed programs, guidelines and policies to address unique operational requirements. Furthermore, a comprehensive OHS training program was developed for workplace committee members, managers/supervisors, and employees.
The duties of key stakeholders, as defined by the CLC, were for the most part understood. The Agency's specific OHS accountability framework had not been developed as OHS roles and responsibilities for program administration were in draft form and had not been shared with the branches or the regions.
Data that Treasury Board Secretariat (TBS) required for the OHS program were monitored and reported to the Policy Health and Safety Committee and workplace health and safety committees. However, an OHS monitoring and reporting framework was not fully developed to ensure that pertinent OHS-related information is collected, analysed and communicated to assess the performance of the OHS program and identify impediments to the implementation of the program. The Agency did not know the extent of compliance of workplace committees with the CLC Part II and related regulations requirements. Except for the OHS orientation course for employees, the extent of completion of OHS-related mandatory training was not known, and individuals who did not complete it were not being identified. There was also no defined process to ensure adherence to guidelines for emergency plans and fire drills.
Opportunities for improvement were noted to strengthen the framework in areas of program accountabilities, responsibilities of the OHS committees and health and safety representatives, monitoring and reporting, and the provision of OHS training and information to employees.
Management Response
The Human Resources Branch agrees with the findings of the Internal Audit Report and has included action plans within the Human Resources Branch Management Plan for 2009-12 to address the recommendations.
In January 2007, in accordance with a new Canada Occupational Health and Safety Regulation (Part XIX – Hazard Prevention Program), the Human Resources Branch developed and implemented, in consultation with the national Policy Health and Safety Committee, a Hazard Prevention Program (HPP). One of the requirements of the Regulation is that employers must conduct an internal evaluation of the effectiveness of their HPP every three years, which for the Agency is due in January 2010. The internal audit team's comprehensive review of the OHS program and the findings and recommendations contained in the Internal Audit Report will greatly assist the Human Resources Branch in completing that process.
In addition, with the upcoming upgrade to the SAP software, the Human Resources Branch is currently finalizing its business requirements document to support the creation of an OHS section within the Corporate Administration System (CAS) that will allow for expanded data capture of information related to hazardous occurrence reports, workplace committee activities, training records, updates of emergency evacuation plans, and scheduling of fire drills. The target date for completion of this project, assuming it remains on track, is scheduled for the spring of 2011.
Introduction
Background
It is the policy of the federal government to ensure all employees are provided with a safe and healthy work environment. The Canada Labour Code (CLC) Part II establishes the legislative framework and outlines the duties and responsibilities of the employer and employees pertaining to occupational health and safety (OHS). Each duty outlined in the CLC has a corresponding regulation prescribing specific requirements.
The CLC requires that all federal government departments establish health and safety programs to address occupational issues such as accident prevention and investigation, hazards elimination and prevention. The establishment of workplace health and safety committees and the provision of training are also fundamental requirements. OHS programs developed by the departments are to be consistent with Treasury Board Secretariat (TBS) policies, standards and procedures and compliant with the Labour Program of Human Resources and Social Development Canada (HRSDC) and Health Canada directives.
The objective of the Canada Border Services Agency (CBSA) OHS function is to protect the health and safety of CBSA employees at the workplace by complying with all health and safety legislative requirements, approved standards, policies and directives, and by ensuring that employees have the necessary equipment, training, instruction and supervision to safely carry out their duties. The Human Resources and Operations branches had the primary responsibility for the OHS program. An overview of the Agency's OHS organizational structure is noted in Appendix A – Table 1.
The Agency's employee population constitutes approximately 14,000. There were 102 workplace health and safety committees and 160 health and safety representatives in place at the time of the audit. According to statistical information for the period of January 1, 2007 to March 31, 2009, 682 hazardous occurrences were reported within the CBSA. Minor injuries accounted for 75% of the hazardous occurrences reported. Disabling injuries were the second most common type of injury accounting for 21%.
The Agency's OHS function has not been the subject of a formal departmental internal audit since the Agency's creation in December 2003. However, an audit conducted by the legacy Canada Customs and Revenue Agency (CCRA) in fiscal year (FY) 2002/03 recommended improvements in the following areas:
- Maintaining existing training products and developing additional training products and training plans for front-line supervisors, employees, and workplace committees;
- Integrating health and safety responsibilities into the culture of the organization;
- Clarifying roles and responsibilities of key players in relation to the CLC Part II;
- Monitoring and supporting field staff with the CLC Part II responsibilities; and
- Strengthening the integrity and reliability of data.
The results of the CCRA audit were issued in September 2004 to the then newly created Canada Revenue Agency – after the reorganization that lead to the creation of the CBSA as a separate agency. In the course of this audit, the internal audit team reviewed the recommendations of the CCRA audit that were relevant to the objective of this audit.
Given the importance of this function in the workplace, an audit of this function was included in the Three-year Risk-based Audit Plan for fiscal year 2008/09–2010/11.
Risk Assessment
To determine potential priorities and areas for audit, a risk assessment was conducted with a focus on the OHS Management Control Framework (MCF) in place[ 1 ], the five occupational safety and health "modules" identified in the CBSA Draft Process Monitoring Framework [ 2 ], and new initiatives in the Agency, including the Doubling-up Initiative and Occupational Health Assessment.
Risk areas identified as critical to the establishment of a safe and healthy workplace and the accomplishment of the Agency's mandate included: (1) the Agency's OHS Management Control Framework (MCF); (2) First Aid; (3) Tools, Equipment, and Uniforms; (4) Employment Hazards/Conveyance Search; (5) Emergency/Business Continuity Plans; (6) the Doubling-up Initiative; and (7) Occupational Health Assessment.
The risk assessment suggested an audit of the Management Control Framework (MCF) as the first CBSA audit in the OHS area, since a sound MCF increases the likelihood that the objectives of a program are achieved.
With regard to the area of emergency/business continuity plans, an audit of emergency preparedness was conducted in FY 2007/08 and an audit of CBSA's business continuity plans or business resumption plans is currently underway. Its planned reporting timeframe is FY 2009/10. With regard to the remaining areas, the Agency was working on these areas/initiatives. Therefore, it was recommended that these areas be considered as part of the annual risk-based planning exercise.
Audit Objective and Scope
The audit objective was to provide assurance on the effectiveness of the Agency's OHS Management Control Framework to promote compliance with the requirements of the Canada Labour Code (CLC) Part II and its regulations.
Fifteen workplaces from the Greater Toronto Area, Prairies, and Atlantic regions were selected for the detailed examination, of which ten were represented by workplace health and safety committees (WPHSCs) and five by health and safety representatives. In addition, 15 randomly selected workplaces, located mainly in remote areas, were surveyed to determine the state of controls at these workplaces. The fieldwork was conducted between February and April 2009. The scope focused on activities from January 1, 2007 to March 31, 2009.
Approach and Methodology
The methodology used in this audit included the following:
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Conduct of a preliminary survey for testing and finalizing of the audit program.
-
Review of applicable legislation, regulations, policies, and procedures.
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Interviews to assess the administration of the OHS program. Interviewees included the Agency's senior management, OHS management and advisors, committee members (i.e., "employee" and "employer representatives"), OHS clients (line managers/supervisors who have OHS responsibilities and require the services of OHS staff), first aid attendants, and OHS service recipients.
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Consultations with federal government organizations (that provide guidance and standards to assist public service managers in interpreting and applying the requirements of the CLC Part II) during the audit fieldwork. This included the TBS and the Labour Program of the HRSDC.
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Documentation and analysis of management controls, and monitoring and reporting practices related to OHS.
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Site visits to review whether specific requirements of the CLC Part II and related regulations were met. The on-site work included: (a) interviews; (b) a sampling of documents, minutes, and records pertaining to employee safety, activities of the workplace health and safety committees at the selected sites, and OHS-related additional support documentation provided by staff; and (c) visual observation of first aid stations. [ 3 ]
Audit Criteria
Criteria for this audit were developed based on: (a) recognized management control frameworks, including the Draft Core Management Controls Framework developed by TBS; and (b) federal authorities, including CLC Part II and related regulations. Detailed audit criteria are provided in Appendix B.
Statement of Assurance
This audit engagement was planned and conducted in accordance with the Internal Auditing Standards for the Government of Canada.
Audit Opinion
The Agency has a governance structure in place and has implemented a number of programs and initiatives based upon risks to promote a healthy and safe workplace. The Management Control Framework for the Occupational Health and Safety Program was partially effective to ensure compliance with mandatory requirements of the CLC Part II and its regulations. Opportunities exist to strengthen the framework in the areas of program accountabilities and responsibilities, planning, and program monitoring.
Findings, Recommendations and Management Action Plan
The organizational and governance structures were established to administer and oversee OHS activities. Overall guidance was provided by the Policy Health and Safety Committee. The members of workplace committees and health and safety representatives demonstrated a high level of dedication in addressing safety issues. The Agency developed programs, guidelines and policies to address unique operational requirements. Furthermore, a comprehensive OHS training program was developed for workplace committee members, managers/supervisors, and employees.
The duties of key stakeholders, as defined by the CLC, were for the most part understood. The Agency's specific OHS accountability framework had not been developed as OHS roles and responsibilities for program administration were in draft form and had not been shared with the branches or the regions.
Data that Treasury Board Secretariat required for the OHS program were monitored and reported to the Policy Health and Safety Committee and workplace health and safety committees. However, an OHS monitoring and reporting framework was not fully developed to ensure that pertinent OHS-related information is collected, analysed and communicated to assess the performance of the OHS program and identify impediments to the implementation of the program. The Agency did not know the extent of compliance of workplace committees with the CLC Part II and related regulations requirements. Except for the OHS orientation course for employees, the extent of completion of OHS-related mandatory training was not known, and individuals who did not complete it were not being identified. There was also no defined process to ensure adherence to guidelines for emergency plans and fire drills.
Opportunities for improvement were noted to strengthen the framework in areas of program accountabilities, responsibilities of the OHS committees and health and safety representatives, monitoring and reporting, and the provision of OHS training and information to employees.
Program Management
Governance for OHS
Subsection 134.1 (1) of the CLC Part II states that "every employer who normally employs directly three hundred or more employees shall establish a policy health and safety committee."
The CBSA established a national Policy Health and Safety Committee (PHSC) to address health and safety matters and promote health and safety of its employees through the development, implementation, and monitoring of the OHS policies and programs. Through the PHSC, CBSA management worked with union representatives to ensure that appropriate consultation took place on all health and safety concerns affecting employees.
The PHSC had an approved Terms of Reference that clearly outlined the Committee's powers and duties, frequency of meetings, and minutes keeping. The duties were derived from subsection 134.1(4) of the CLC Part II. Committee meetings were held quarterly, and minutes were adequately recorded and distributed. Members had the responsibility and authority to make decisions and were representative of the organization.
The Agency had been a member of the National Joint Council OHS Committee since 2005 and participated in the forum with federal departments and agencies to discuss issues on an interdepartmental level.
CBSA OHS Principles and Policies
Agency OHS policies, guidelines and procedures should provide the necessary guidance to promote the creation of a healthy and safe workplace.
The Agency was governed by the CLC Part II and its regulations,[ 4 ] and TBS OHS policies and directives. On the intranet, the Agency stated its commitment to protecting the health and safety of its employees at the workplace "by complying with all health and safety legislative requirements, approved standards, policies and directives, and by ensuring that employees have the necessary equipment, training, instruction and supervision to safely carry out their duties on behalf of the employer."
Agency policies and guidelines were developed to address unique operational requirements related to occupational health and safety, such as arming, doubling-up, respiratory protection, etc. Interviewees indicated that existing policies provided sufficient guidance to promote a healthy and safe environment in their workplaces.
OHS Program Accountabilities
Accountabilities and responsibilities should be clearly defined and assigned to ensure successful implementation of the OHS program.
The Agency's OHS organizational structure associated with the OHS program was shared and had been established. The duties of key stakeholders, as defined by the CLC (Appendix A –Table 2), were for the most part understood by key stakeholders. The Agency's specific OHS accountability framework had not been developed as OHS roles and responsibilities for program administration were in draft form and had not been shared with the branches or the regions.
Based on a survey of practices of other federal organizations, the audit noted that those organizations clearly stated who in their organization was accountable and responsible in their organization's general OHS policy or a manual had been developed. Without a formal acknowledgement and acceptance of accountabilities and specific responsibilities, responsibilities may not be adequately or consistently performed.
Recommendation:
1. The Vice-President of the Human Resources Branch, in collaboration with other affected branches, should develop and implement the Agency's OHS accountability framework.
| Management Action Plan | Completion Date |
|---|---|
The Human Resources Branch will, in collaboration with other affected branches, and the regions, develop and implement an accountability framework for the Agency's Occupational Health and Safety Program that clearly sets out roles and responsibilities. |
June 30, 2010 |
|
December 31, 2009 |
|
March 31, 2010 |
|
June 30, 2010 |
Workplace Committees and Health and Safety Representatives
The TBS Manager's Handbook CLC Part II states that "all employees, in workplaces at which one or more employees are regularly employed, will be represented by either a Workplace Health and Safety Committee (WPHSC) or a Health and Safety Representative." Under subsection 135.(1) of the CLC Part II "every employer shall, for each workplace controlled by the employer at which twenty or more employees are normally employed, establish a workplace health and safety committee." Under subsection 136.(1), in workplaces where there are fewer than 20 employees, there must be a health and safety representative selected by the employees to address and report OHS issues to management.
The audit confirmed that WPHSCs were established and health and safety representatives were appointed at the workplaces selected for audit. Interviewed WPHSC members and health and safety representatives demonstrated a high level of dedication and commitment to ensuring safe workplace conditions.
Based on the review of the documentation for the ten workplaces selected for the detailed examination that had established WPHSCs, the audit found that the requirements of the CLC Part II and the Safety and Health Committees and Representatives Regulations were not always met:
- Five of the ten WPHSCs did not have up-to-date approved rules of procedure. [ 5 ]
- Five of the ten WPHSCs did not have sufficient documentation to demonstrate that they comply with the meeting frequency requirement (i.e., to hold nine meetings a year). In addition, the minutes were not always signed by both co-chairs.
- Two of the ten WPHSCs conducted monthly inspections and documented their results. Three WPHSCs did not have any records to demonstrate that the inspections took place. The remaining WPHSCs conducted, on average, two to three inspections a year.
For the 17 workplaces[ 6 ] that appointed health and safety representatives, the audit was advised that one had performed monthly inspections and documented their results. The remaining workplaces advised that they performed inspections one to two times a year and the results of the inspections were not always documented.
The audit noted that WPHSC members, health and safety representatives, and regional OHS personnel were not always aware of the specific requirements of the CLC Part II (i.e., documented monthly inspection). Based on interviews, the training for WPHSC members and health and safety representatives provided an overview of their responsibilities and useful tools (e.g., guidelines, checklists, procedures). However, additional tools were suggested to facilitate their performing of those responsibilities (i.e., a consolidated checklist of responsibilities; a national template for recording OHS minutes). A lack of effective support and guidance to the regional offices may result in CBSA not meeting its obligations under CLC Part II.
Recommendation:
2. The Vice-President of the Human Resources Branch should ensure that workplace committees and health and safety representatives have a better understanding of their responsibilities under the CLC Part II and are provided with the necessary tools to perform their duties.
| Management Action Plan | Completion Date |
|---|---|
The Human Resources Branch will develop and provide national tools to the regions (i.e. consolidated checklists outlining roles and responsibilities of workplace committees and representatives; and templates for meeting agendas, minutes, and workplace inspections) to ensure that there is consistency and a common understanding of workplace committee members and health and safety representatives duties and responsibilities under the CLC Part II. These national tools will be made available electronically on the Agency's intranet site. |
March 31, 2010 OPI: Labour Relations and Compensation Directorate |
Risk Management
Mechanisms are expected to be in place to ensure that risks are documented, communicated and managed in a timely manner.
The PHSC reviewed and addressed high priority OHS issues and monitored implementation of OHS plans. Conference calls took place quarterly to provide an opportunity to discuss national and working level issues related to implementation of OHS. Participants included representatives from the OHS Section and OHS Regional Coordinators. Based on interviews and observations, measures were also in place to mitigate the identified potential high-risk areas (e.g., protective equipment, job specific training, updated Material Safety Data Sheets).
The Comptrollership Branch, responsible for providing functional guidance on the emergency planning portfolio, had established guidelines for emergency plans and fire drills in the Agency's Security Manual. [ 7 ] The audit noted that a monitoring process was not established to ensure adherence to these guidelines. At the 15 locations selected for detailed examination:
- eight of the thirteen workplaces, for which Emergency Evacuation Plans were developed, had not been tested; one workplace was not required to develop the plan and the other had developed a plan that was not yet approved.
- nine workplaces did not perform fire drills in 2008. Five out of these nine were workplaces in multi-tenant buildings. Based on interviews, compliance with legislative requirements in workplaces with multiple tenants was a concern, and these workplaces experienced constraints in performing fire drills due to operational requirements (e.g., 24/7 operations, high-volume passenger/commercial traffic).
Testing of plans and fire drills are important risk mitigation activities to protect the safety of individuals in the event of a fire, general disaster or security threat.
Risk-Based Planning
Operational risk-based plans should be developed, resourced and implemented to provide guidance and direction for the successful implementation of the OHS program.
The CBSA had initiated a risk-based approach and undertaken various initiatives to reduce the incidence of occupational injuries and illness. Most notably this included a Hazard Prevention Program, a formal program for conducting job hazard analyses, taking any corrective actions, and ensuring stakeholders are aware of the program and their responsibilities. Many of the Agency jobs had been assessed through one of the Job Hazard Analyses (JHA) that commenced in 2003.
As the lead for the management and coordination of JHA files, the Officer Safety Unit in the Operational Performance and Readiness Directorate, Operations Branch, developed a workplan for FY 2007/08. This document defined planned activities, associated full-time equivalents (FTEs) and dollar resource requirements. The Policy Health and Safety Committee (PHSC monitored the progress in the implementation of the plan. The Operations Branch pointed out that the plan was not updated for 2008/09, as the priorities had remained the same.
The Human Resources Branch Key Priority Plan for FY 2008/09 identified key priorities and associated activities for the Labour Relations and Compensation Directorate, which included the OHS Section. However, the OHS Section had not developed a detailed annual work plan to set out OHS-related new and ongoing projects/activities, estimated level of effort, and associated resource requirements.
Without a well-established operational planning process, planned activities may not be appropriately prioritized and funded; challenges may not be addressed; commitments of the OHS program may not be aligned; and the program progress may be difficult to assess.
Recommendation:
3. The Vice-President of the Human Resources Branch should ensure that an annual work or operational plan for ongoing and new projects and initiatives be developed for the OHS program.
| Management Action Plan | Completion Date |
|---|---|
The Human Resources Branch will ensure that annual detailed work plans for new and ongoing OHS projects/activities are developed, estimated level of effort associated with the planned activities identified, and associated estimated resource requirements are forecasted. |
Initial Work Plan to be completed by December 31, 2009, and annually thereafter. OPI: Labour Relations and Compensation Directorate |
Training/Awareness
The CLC Part II, section 125(1) and the TBS Occupational Health and Safety Directive requires that: (1) each employee be provided with the information, instruction, training and supervision necessary to ensure their health and safety at work; (2) employees, who have supervisory or managerial responsibilities, be adequately trained in health and safety and are informed of the responsibilities they have under CLC Part II; and (3) members of policy and workplace committees and health and safety representatives receive the prescribed training in health and safety and are informed of their responsibilities.
The Agency had an OHS training program in place, which included: OHS training modules for employees, managers/supervisors, and committee members[ 8 ]; individuals trained to deliver the OHS training for committee members and health and safety representatives; an evaluation of the training modules, as part of the review of the OHS course modules. In addition, the Agency's OHS website, provided reference materials and numerous Web links to assist stakeholders.
The majority of employees had completed the online orientation training. However, the audit noted that a number of individuals had not completed or completed in a timely manner the following OHS mandatory training:
- OHS training for managers and supervisors: Based on the CAS data, 37% of the managers and supervisors had completed the training on April 1, 2009. Managers/supervisors in acting positions had not taken the training.
- Training for committee members and health and safety representatives: Based on the survey of the workplaces selected for audit, committee members and health and safety representatives were not provided with the training on a timely basis. [ 9 ]
- Workplace Hazardous Materials Information System (WHMIS) training: The extent of completion of the online WHMIS training was unknown as attendance requirements were not monitored.
Based on interviews, the OHS training for committee members and health and safety representatives and managers was not readily available. The regions advised that this gap was being addressed via the training of a sufficient number of "trainers" and the offering of training sessions.
In terms of quality of training, most interviewees viewed OHS training they had taken as useful and providing sufficient and relevant information. Interview results and observations indicated that specific CLC Part II requirements and Agency processes were not always understood by committee members. For example the following two areas were identified:
- Frequency of Workplace Inspections: In a number of cases, the understanding was that inspections were to be performed once a year as long as all elements of the workplace were inspected at least once a year.
- Investigation and Reporting Process: Clarification and communication were required with regard to the definition of participation in investigations and the reporting of them.
In the audit survey of other federal organizations, a best practice was noted in the establishment of competency profiles for OHS personnel and associated training and/or required a professional designation due to their operations environments.
Monitoring and Reporting
To meet the requirements of the CLC Part II, the Agency must monitor whether its OHS programs are operating effectively and in compliance with the CLC Part II and related regulations. To ensure effective monitoring, performance measures and indicators should be established and results communicated.
The Agency collected seven types of OHS statistics for reporting to the TBS in support of the Management Accountability Framework initiative.[ 10 ] The Agency also collected pertinent information and statistics for review and decision making by the PHSC, such as: (1) updates on implementation of the JHA's recommendations and Doubling-up Initiative; (2) injury statistics and security incidents; (3) work refusals; and (4) employee health and safety orientation training.
In addition, the Operations Branch's Process Monitoring Framework (PMF),[ 11 ] for use by supervisors / superintendents / chiefs / managers, incorporated an OHS component (Section 11 – Occupational Safety and Health) and was distributed to the regions in October 2008. Information was to be collected and communicated via summary exception reports in the following areas: (1) First Aid and Employment Hazards; (2) Security Management; and (3) Radio Communication.[ 12 ] The development of Section 11 included consultations with HQ and the regions. However, the HR Branch, which had functional authority for specific OHS areas, had not been consulted in the development of the document.
Although a number of OHS statistics and information were collected and a part of the OHS monitoring and reporting framework was established via the PMF, an overall OHS performance measurement and monitoring framework had not been established to:
- identify all key performance indicators and measures (e.g. number of committee meetings, inspections, attendance at selected OHS training); and
- specify regional and Headquarters monitoring and reporting responsibilities, including frequency for monitoring activities.
As a result, not all pertinent OHS-related statistics/information were collected and analysed. For example, the Agency did not know the extent of compliance of workplace committees with the CLC Part II and related regulations requirements; or the extent to which OHS-related mandatory training was taken and did not identify individuals who did not complete the training (except for the OHS orientation course for employees). The Corporate Administrative System (CAS) had functionalities to support the collection of OHS training information. However, not all OHS training information had been properly tracked in CAS, such as the WHMIS training, and the training for workplace committee members, and health and safety representatives.
As well, the audit noted that the level of compliance monitoring and type of monitoring performed by Regional OHS Coordinators varied significantly from one region to another. Based on interviews, the Regional OHS Coordinators understood their overall monitoring responsibilities; however, the minimum monitoring requirements for the Regional OHS were not defined and communicated.
Without a formally established OHS monitoring and reporting framework, management may not be able to assess the performance of the OHS program and the extent of compliance with the CLC, identify impediments to the implementation, or support decision making.
Recommendation:
4. The Vice-President of the Human Resources Branch, in collaboration with the Operations and Comptrollership branches and the Policy Health and Safety Committee, should strengthen and implement a monitoring and reporting framework (including monitoring and reporting on workplace committees' performance, emergency planning and management, and training and awareness).
| Management Action Plan | Completion Date |
|---|---|
The Human Resources Branch will, in collaboration with the Operations and Comptrollership branches, and in consultation with the Policy Health and Safety Committee, strengthen the current health and safety reporting and monitoring framework by developing guidelines that will assist at the local, regional, and national levels for effective monitoring of workplace committees / health and safety representatives activities; health and safety training; and emergency evacuation planning. |
June 30, 2010 |
|
March 30, 2010 |
|
March 30, 2010 |
|
June 30, 2010 |
Appendix A: Roles and Responsibilities
Table 1: CBSA OHS Organizational Structure
Human Resources Branch
The Human Resources Branch had the overall responsibility for the OHS program within the Agency. The OHS Section was established as part of the Occupational Health and Safety / Duty to Accommodate and Disability Management Division in the Labour Relations and Compensation Directorate. The mandate of the OHS Section is to provide functional advice and guidance throughout the Agency, and support the development, implementation, and monitoring of the Agency's OHS program. At the time of the audit, the Section comprised five FTEs.
Operations Branch
The Officer Safety Unit, established in 2006 as part of the Programs and Operational Services Directorate, was responsible for advancing issues relating to the health and safety of front-line officers. At the time of the audit, the Unit comprised eight FTEs.
The Unit was the Office of Primary Interest (OPI) for the management and coordination of all job hazards analysis (JHA) files. It was the point of contact for the regions and other headquarters directorates in providing guidance and expertise in the delivery of the recommendations named in the existing JHAs.
Comptrollership Branch
The Infrastructure and Environmental Operations Directorate was responsible for promoting a safe working environment via the design, planning, construction and improvements of the CBSA infrastructure. The Security and Professional Standards Directorate was responsible for providing functional guidance on the emergency planning portfolio.
Regions and Branches
Regional Directors of Human Resources had overall accountability for the OHS function in their respective regions. The Regional OHS Coordinators were assigned with specific OHS responsibilities, including: providing OHS functional guidance to regional managers, WPHSC, and health and safety representatives in meeting their OHS responsibilities; monitoring workplaces for compliance with CLC requirements; and coordinating the delivery of OHS programs in their respective regions.
All managers and supervisors, at any organizational level of the Agency, were responsible for ensuring compliance with the CLC and implementation of OHS within their respective areas of responsibility.
Table 2: Duties for Operational Health and Safety in the Public Service as Defined by the CLC Part II
Employers
Under section 124 of the CLC Part II, employers have a general obligation or duty to ensure that the health and safety of every person employed by the employer is protected while they are working.
Under subsection 125.(1), specific duties are assigned to employers with respect to each workplace they control and every work activity under their authority that occurs in a workplace that is beyond their control.
Employees
The CLC Part II places several obligations on employees, all of which have the goal of preventing occupational related injuries and diseases. Under subsection 126.(1), employees have a responsibility to take all reasonable and necessary precautions to ensure their health and safety and that of anyone else who may be affected by their work or activities.
Policy Health and Safety Committees
Under subsection 134.1(1), every employer who normally employs directly 300 or more employees shall establish a policy health and safety committee. Policy Health and Safety Committees have the responsibility to address organization-wide issues via a range of activities, including: development and implementation of health and safety hazard prevention programs; development and implementation of violence prevention programs; planning and implementing changes, work processes and procedures that may affect health and safety; development of health and safety policies and programs; and development, implementation and monitoring of a personal protective equipment program.
Workplace Health and Safety Committees
Under subsection 135.(1), every employer shall, for each workplace controlled by the employer at which 20 or more employees are normally employed, establish a workplace health and safety committee. The CLC Part II gives employees, via WPHSCs, the legislated right and responsibility to participate in identifying job-related health and safety concerns and implementing health and safety policy and programs in their workplace. Specific duties of the WPHSCs are outlined in subsection 135.(7).
Health and Safety Representatives
Under subsection 136.(1), in workplaces where there are fewer than 20 employees or in workplaces exempted from the committee requirement, there must be a health and safety representative selected by the employees who do not exercise managerial functions, or by the union after consulting any employees who are not in the union. Specific duties of health and safety representatives are outlined in subsection 136.(5). They have been given the same expanded powers, authorities and protection as those given to committees.
Appendix B: Audit Criteria
| Lines of Enquiry | Audit Criteria |
|---|---|
| Adequacy and Effectiveness of the OHS Management Control Framework [ 13 ] | 1.1 Governance: An effective OHS oversight structure has been established within the CBSA and meets the requirements of the CLC Part II and related regulations. |
| 1.2 Accountability/Responsibility: Management and OHS personnel formally acknowledge their understanding and acceptance of the responsibilities. | |
| 1.3 Policies, Procedures and Guidelines: The Agency's OHS policies, guidelines and procedures are consistent with applicable federal government legislation, regulations and policies, and provide the necessary guidance to promote the creation of the healthy and safe workplace. | |
| 1.4 Planning and Risk Management: Operational risk-based plans have been developed, resourced and implemented to provide guidance and direction, and monitored to achieve successful implementation of the OHS program. | |
| 1.5 Monitoring and Reporting: Formal monitoring and reporting mechanisms are in place to ensure that the OHS program is administered in compliance with the authorities and to appropriately respond to any arising issues. | |
| 1.6 Awareness, Training, and Competencies: OHS training and awareness programs are in place to ensure that all stakeholders are provided with the necessary knowledge and skills to understand their rights and discharge their OHS responsibilities. |
Appendix C: List of Acronyms
- CAS
- Corporate Administrative System
- CBSA
- Canada Border Services Agency
- CLC
- Canada Labour Code
- CCRA
- Canada Customs and Revenue Agency
- CRA
- Canada Revenue Agency
- FTEs
- full-time equivalents
- FY
- fiscal year
- HPP
- Hazard Prevention Program
- HR
- human resources
- HRB
- Human Resources Branch
- HRSDC
- Human Resources and Social Development Canada
- JHA
- Job Hazard Analysis
- MCF
- Management Control Framework
- OHS
- Occupational Health and Safety
- OPI
- office of primary interest
- PHSC
- Policy Health and Safety Committee
- PMF
- Process Monitoring Framework
- TBS
- Treasury Board Secretariat
- WHMIS
- Workplace Hazardous Materials Information System
- WPHSC
- Workplace Health and Safety Committee
Notes
- The areas selected for the assessment were identified based upon the elements of the management control framework referenced in the Draft Core Management Controls, Office of Comptroller General, November 2007. [Return to text]
- September 2008, CBSA Draft Process Monitoring Framework, Tier 1 – Phase Two, Section 11 – Occupational Safety and Health references the following five modules as essential for the promotion of a healthy and safe workplace at the CBSA: (1) First Aid and Employment Hazards; (2) Tools, Equipment, and Uniforms; (3) Conveyance Search /Examination; (4) Security Management; and (5) Radio Communication. [Return to text]
- Section 16.5 (1) of the Canada Occupational Health and Safety Regulations requires that at least one first aid station be provided for every workplace. [Return to text]
- The legislation is specifically intended to "prevent accidents and injury to health arising out of, linked with or occurring in the course of employment," CLC- Section 122.1.[Return to text]
- Subject to subsections 134.1(7) and 135.1(10) and any regulations made under subsection 135.2(1) of the CLC Part II, a workplace committee shall establish its own rules of procedure in respect of the terms of office, of its members and the time, place and frequency of regular meetings of the committee, and may establish any rules of procedure for its operation that it considers advisable. It is preferable that core rules of procedure for workplace committees be established centrally in consultation with the policy committee and made applicable to all workplaces and the appropriate committees. Refer to TBS Manager's Handbook Canada Labour Code - Part II, Chapter 6, Policy Health and Safety Committees, subsection (14).[Return to text]
- For the 17 workplaces with the OHS representatives, five were selected for the detailed examination (which included documentation review of inspections, emergency evacuation plans, fire drills and training records) and 12 workplaces were surveyed. [Return to text]
- The Agency's Security Volume, Chapter 3, paragraph 22 states that: "Emergency plans, other than fire evacuation plans, must be tested at least every two years. Tabletop exercises are an effective means of evaluating a plan."
The Agency's Security Volume, Chapter 3, paragraph 19 states: "There must be at least one total building evacuation drill each year involving all occupants in the building... A record of each drill in the building must be kept for a period of 2 years from the date of the drill." [Return to text] - The Agency OHS training modules included: (1) online OHS orientation course for employees; (2) an OHS training module for managers/supervisors; (3) a two-day course for committee members and OHS representatives; and (4) an online Workplace Hazardous Management Information System. [Return to text]
- The OHS training was considered to be provided on a "timely basis" if it was taken within six months by an individual who became a WPHSC member or an OHS representative.[Return to text]
- TBS had established limited reporting requirements in support of the management accountability framework initiative, including: (1) number of employees managing the OHS program; (2) valid OHS grievances; (3) valid OHS complaints (per section 127.1 of the CLC); (4) confirmed work refusals (per section 128 of the CLC); (5) directions issued by HRSDC; (6) number of supervisors/managers requiring training; and (7) number of supervisors/managers trained in the last three years. [Return to text]
- The PMF is an integrated review tool of the current, national CBSA programs. It is to be used as a guideline for ongoing operational checks of day-to-day processes, as well as to concentrate on the high-risk and/or sensitive areas of business. [Return to text]
- October 2008, Process Monitoring Framework (v 1.5), Tier 1 – Phase Two, Section 11 – Occupational Safety and Health. [Return to text]
- Linked to Draft Core Management Controls, Office of the Comptroller General, November 2007. [Return to text]
