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Audit Report 2003

FOLLOW-UP AUDIT OF THE OCCUPATIONAL HEALTH AND SAFETY PROGRAM
PROJECT #02/03 01-04

Prepared by
Audit, Evaluation and Review Directorate

April 2003


Executive summary
1.0 Introduction
  1.1 Background
  1.2 Objective and criteria
  1.3 Scope
  1.4 Methodology
2.0 Comments and recommendations on the action plan
  2.1 Actions involving the policy committee
  2.2 Actions involving the human resources directorate
  2.3 Other actions called for in the plan
  2.4 Action plan follow-up table
Appendix 1 - Action plan follow-up table
  1 Management participation
  2 Identification and monitoring of dangers
  3 Work rules and procedures
  4 Training
  5 Communication
  6 Incident and accident reports and investigations
Appendix 2 - Action plan arising from the aerd follow-up audit

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EXECUTIVE SUMMARY

The follow-up audit of the Occupational Health and Safety (OHS) Program revealed that great efforts had been made since the action plan was tabled with the Executive Committee in July 2001. The report tabled by Health Canada in March 1999 presented 36 recommendations, broken down into 6 individual headings.

The following table shows to what extent the action plan has been implemented:

We can see that the actions called for in the plan have to a large extent been implemented. Most actions that have not yet been carried out have a set deadline.

Appendix 1 sets out our comments arising from the follow-up audit for each of the 36 recommendations.

Here are the 4 main concerns raised by the follow-up audit:

  • Some actions called for in the plan involve the Policy Health and Safety Committee (PHSC) , but no such committee is yet active at the Agency.
  • Some actions called for in the plan involve the Human Resources Directorate (HRD) and, in one case, the latter does not agree with the actions identified (1.B.1). In two other cases (1.B.2 and 1.C.1), the HR Directorate, the Policy Committee and the Local Health and Safety Committee (LHSC) should come to an agreement on how these recommendations are to be implemented.
  • Development of an OHS policy would make it possible to advise all staff of the roles and responsibilities of the various OHS stakeholders and thereby fulfil three of the recommendations in the Health Canada report (1.B.1, 6.A.1 and 3.D.1).
  • The HR Directorate recently implemented orientation sessions for new employees. At the first session, which took place on March 13, 2003, basic OHS concepts were dealt with. That was a good start, but there is still much to be done in that area, especially regarding contractuals and visitors.

In our professional judgment, the audit procedures in place and the evidence gathered are appropriate and sufficient to support the accuracy of the conclusions in the report. The conclusions are based on a review of situations identified according to the criteria set out in section 1.2 of this report. The conclusions apply only to the Action Plan developed by the entity being audited to fulfil the recommendations set out in Health Canada’s March 1999 audit report.

This internal audit was carried out in accordance with the Treasury Board’s Policy on Internal Audit and the Standards for the Professional Practice of Internal Auditing of the Institute of Internal Auditors (IIA).

The internal audit revealed that the entity being audited complies with the audit objectives set out in section 1.2 of this report. However, particular attention needs to be paid to the recommendations in section 2.0.

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1.0 INTRODUCTION

1.1 BACKGROUND

The follow-up audit of the OHS Program is scheduled in the work plan of the Audit, Evaluation and Review Directorate (AERD) for the 2002-2003 fiscal year.

A first audit of the OHS Program was carried out by Health Canada in February 1999. The report, issued in March 1999, sets out the various findings and recommendations of this audit.

At that time, the Agency obtained a score of 34.9%. According to Health Canada, considering that this was a first evaluation, it was a golden opportunity to make improvements to the existing health and safety program.

In July 2001, the LHSC presented to the Executive Committee an action plan setting out the actions to be taken to fulfil the recommendations in the Health Canada report.

Through this follow-up audit, we were able to determine to what extent the LHSC had implemented the action plan approved by the Executive Committee on July 11, 2001.

1.2 OBJECTIVE AND CRITERIA

The objective of the follow-up audit was to determine the degree to which the action plan submitted in response to the recommendations of Health Canada in its March 1999 report on the OHS Program had been complied with.

The following audit criteria were used for that purpose:

  • The action plan is complete and reflects all recommendations in the Health Canada report;
  • Deadlines had been set for each of the actions to be taken;
  • Completed actions were identified; and,
  • Reasonable deadlines had been set for actions not yet completed.

1.3 SCOPE

The follow-up audit dealt with all actions set out in the LHSC’s action plan to fulfil Health Canada’s recommendations in its March 1999 report.

The audit was done in January and February 2003.

For the purposes of its audit, Health Canada used an “audit protocol” in which a score was assigned to each audit criterion. The elements on which the Agency was evaluated were the following:

  • Management participation
  • Identification and monitoring of dangers
  • Work rules and procedures
  • Training
  • Communications
  • Incident and accident reports and investigations

The Agency had a score of 206 out of a possible 590 points, or 34.9%.

1.4 METHODOLOGY

The follow-up audit was carried out in accordance with the TB Policy on Internal Audit, which requires, in particular, that audit objectives be set based on audit criteria. To this end, one of the methods employed by the auditor was to interview managers and employees involved in the management of the OHS Program. The auditor did a sample analysis of a number of records, reports and files maintained by staff.

The auditor provided periodic verbal reports to keep the entity being audited informed about how the audit project was progressing.

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2.0 COMMENTS AND RECOMMENDATIONS ON THE ACTION PLAN

2.1 ACTIONS INVOLVING THE POLICY COMMITTEE

  • The Agency’s PHSC has only one member, so it is not yet operational. According to the Canada Labour Code – Part II, in force as of Septembre 30, 2000, any employer with a staff of 300 or more should implement a PHSC.
  • In view of the foregoing, the actions called for in the plan were mainly assigned to the LHSC, which is therefore quite overburdened. It is important to look at the responsibilities that should be assumed by each of these committees at the Agency, i.e. LHSC and PHSC, to ensure that the actions have been assigned to the right committee.
  • Some actions called for in the plan, in particular with respect to the drafting of an OHS policy or the implementation of OHS orientation sessions, have been assigned to LHSC, whereas PHSC should also participate in these actions in view of the stipulations of the Treasury Board (TB) Manager’s Handbook Canada Labour Code – Part II, which states that PHSC:
    • Shall participate in the development of health and safety policies and programs;
    • Shall consider and expeditiously dispose of matters concerning health and safety raised by members of the committee or referred to it by a local committee or a health and safety representative;
    • Shall participate in the development and monitoring of a program for the prevention of hazards in the work place that also provides for the education of employees in health and safety matters (to be developed in conjunction with local committees and conducted with their participation);
    • Shall participate to the extent that it considers necessary in inquiries, investigations, studies and inspections pertaining to OHS;
    • Shall co-operate with health and safety officers;
    • Shall participate in the planning of the implementation and in the implementation of changes that might affect OHS, including work processes and procedures
  • The Manager’s Handbook also states:

    “Policy committees are expected to perform an oversight function, be involved in resolving health and safety issues that affect more than one workplace and be involved in decisions that impact on the entire organization. Committee members are expected to be at a level in management and unions capable of making those decisions.”

  • As regards local committees, the Manager’s Handbook also states:

    “Although departmental or agency-wide programs will be primarily developed at the Policy Committee level, monitoring and implementation will be carried out at the local level.”

  • The Manager’s Handbook mentions, in particular, that the local committee, in respect of the workplace for which it has been established:
    • Shall consider and expeditiously dispose of complaints relating to the health and safety of the employees;
    • Shall participate in the implementation and monitoring of the preventive program laid down in the regulations and developed in consultation with the Policy Committee;
    • Shall participate in all inquiries, investigations, studies and inspections pertaining to OHS;
    • Shall participate in the implementation of changes that may affect OHS, including work processes and procedures;
  • For reference purposes, the Treasury Board’s Manager’s Handbook Canada Labour Code – Part II, Chapter 1 – Overview, sets out the general rules pertaining to PHSC and LHSC. A few of these rules were given above, but this document should be consulted to help both committees better identify the roles and responsibilities to be assigned to them.

RECOMMENDATION

That a PHSC be established and work with the LHSC to determine their respective roles and responsibilities, since both committees are closely concerned with the management of the OHS Program.

A number of actions planned in response to the recommendations in the Health Canada report call for co-operation between the PHSC and the LHSC.

2.2 ACTIONS INVOLVING THE HUMAN RESOURCES DIRECTORATE

There was no unanimous agreement on Actions 1.B.1 and 1.B.2 (Safety and health responsibilities) and 1.C.1 (Communications with management) regarding the actions to be taken to respond to the stated recommendations.

The Director of the HR Directorate told us he did not agree with the planned actions on the 1.B.1 recommendations. Appendix 1 sets out the main points of disagreement that will have to be discussed between HR and the OHS committees to come up with an action plan acceptable to all concerned.

ACTION 1.B.1

Following a review of the situation with respect to recommendation 1.B.1, we believe that one way of making all employees aware of the roles and responsibilities of the various OHS stakeholders regarding, among other things, tasks, the frequency and the person in charge, would be to have an OHS policy approved by the PPP Committee.

In its report, Health Canada also mentioned that the incumbent of the position having responsibility for carrying out the task must be identified. To respond to this recommendation, positions with OHS duties in sectors at risk could be identified in an appendix to the policy.

As for the section on performance measurement, successive inspections will show whether there has been any improvement in OHS in workplaces, which, in general, are under the responsibility of clearly defined positions. On this basis, managers should be able to assess performance.

RECOMMENDATION

Review the planned action to respond to this Health Canada recommendation in order to achieve consensus between all concerned. No matter which option is chosen, it should be acceptable to all concerned, and an implementation timetable should be set.

ACTION 1.B.2

Our discussions with the Director of the HR Directorate showed that it would be possible to add wording specifying the OHS elements to be evaluated to the user’s handbook “Evaluation Report on Performance and Commitments for the Next Evaluation Period”, which is available on the Intranet. Again, it should be noted that successive inspections in a given sector will also enable us to assess whether responsibilities assigned to particular sectors/positions were in fact discharged.

RECOMMENDATION

The OHS committees ought to embark on discussions with the HR Directorate to reach an agreement on how to implement this action.

ACTION 1.C.1

With respect to this action, our discussions with the Director of the HR Directorate revealed that the latter was willing to have an OHS recognition program set up. Moreover, he thought it was up to the LHSC and the PHSC to do the needful (define selection criteria, rules, etc.). The HR Directorate, for its part, is ready to provide support during this undertaking and subsequently in order to obtain the required approvals with the TB to ensure that the recognition program respects the TB policies in that regard.

RECOMMENDATION

That the LHSC and the PHSC reach an agreement with the HR Directorate on how to implement this action.

2.3 OTHER ACTIONS CALLED FOR IN THE PLAN

  • The drafting of an OHS policy is among the actions outlined in the action plan reviewed. This policy would make it possible to advise all staff of the roles and responsibilities of the various OHS stakeholders and thereby fulfil three of the recommendations in the Health Canada report (1.B.1, 6.A.1 and 3.D.1).

    RECOMMENDATION

    Review the proposed March 2003 deadline for the development of an OHS policy.

  • The Health Canada report contains four recommendations on health and safety orientation sessions (4.A.1, 4.A.2, 4.A.3 and 5.B.3). Some measures have already been taken by the HR Directorate to organize orientation sessions for new employees. At the first session, which took place on March 13, 2003, basic OHS concepts were discussed. That was a good start, but there is still much to be done in that area, especially regarding contractuals and visitors.

    No recommendation, since measures are already called for in the plan and the deadlines have not yet been reached.

2.4 ACTION PLAN FOLLOW-UP TABLE

The table presented in Appendix 1 gives details on:

  • Recommendations made by Health Canada in its March 1999 report;
  • Actions to be taken to correct deficiencies identified by Health Canada, with a timetable; and
  • Comments from the follow-up audit and an indication of whether the action plan called for was in fact implemented.

RECOMMENDATION

Each person responsible for the actions identified in Appendix 1 must, in addition to the recommendations that emerge from this follow-up audit—shown in Appendix 2—continue to implement the action plan of the OHS Program developed following the Health Canada audit.

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APPENDIX I - ACTION PLAN FOLLOW-UP TABLE

1. MANAGEMENT PARTICIPATION

Health Canada recommendations Action plan Resources Deadline Follow-up audit AERD Comments
A.0 Health and safety policy

A.1

That the policy statement be modified to mention the requirement for compliance with government regulations.

1. Review according to comments of March 8, 2001.

2. Review after training of April 10, 2001.

 

1. Done

 

2. Done

The September 26, 2001 statement included a reference to occupational health and safety legislation.

A.2

That the policy statement be distributed to all employees. It should be posted in workplaces and be occasionally discussed with employees-at least once a year.

1. Distribute by email.

2. Annual discussions during "OSH Week" and during workplace inspections (formal and informal).

3. To be included in workplace OSH plans on each bulletin board. Managers to be sensitized during inspections

 

1. Done

 

2. Done

 


3. Done

Policy statement posted on central bulletin boards and those of sectors at risk with suspect with OHS plans. It was emailed to all employees by the President of CSA on August 2, 2001.

 

That an occupational health and safety policy be drafted.

(Note: this was not among the 36 Health Canada recommendations.)

Draft the policy and have it approved by the PPP Committee.

PHSC and LHSC

March 2003 - to be reviewed

To be done This recommendation was not part of the Health Canada report but has been added. It is a good initiative, as it will make it possible to respond to the recommendation in B.1 below.
B.0 Occupational safety and health responsibilities

B.1

1. That occupational safety and health responsibilities be drafted to specify who does what and when with respect to the various activities.

2. The task, its frequency and the associated responsibility shall be clearly defined.

3. The incumbent of the position with responsibility for performing the task must be identified.

4. Responsibilities shall be quantifiable, so that performance may be measured or evaluated.

1. Accountability exercise to be performed based on legal provisions and training; Drafting: "who does what".

2. Identify persons responsible (ask for help from HRDC in an advisory role).

3. See that OSH requirements are systematically included in work descriptions, in particular those of supervisors, based on Part II of the Canada Labour Code.

4. Specify a minimum of knowledge of Part II of the CLC in statements of qualifications for supervisor positions:

  • draft wording (HR);
  • identify position numbers on organization charts;
  • write to directors to have them include this in work descriptions and statements of qualifications (HR);
  • consult HR advisers as to how this may be done.

 

 

 

 

 


3. Policy OSH Committee and LOSHC

2003-2004

 


4. Policy OSH Committee and LOSHC

2003-2004

1. Done

 

 

2. Done

 


3. To be reviewed

 

 

 

4. To be reviewed

1. The "who does what" poster has been circulated on bulletin boards and by email and published in the "Capsule newsletter".

2. Positions at risk in the sectors have been identified.

3. In our discussions with the HR Director, he told us he did not agree with action plan items 3 and 4. In his opinion the 126 work descriptions determined to pose a risk to OHS should not be modified to include OHS-related items. Part II of the CLC is part of the knowledge and rules that all employees and employers must know and comply with.

Our review of the situation suggests that those concerned by the corrective measures to be taken have not come to any agreement on what should be done. We believe that one way of making all employees aware of the roles and responsibilities of the various OHS stakeholders and, as regards tasks, how often they are to be done and by whom, would be to have an OHS policy approved by the PPP Committee.

When Health Canada, in its report, speaks of the incumbent of the position with responsibility for performing the task, a general statement of requirements could be used or, if greater specificity is required, positions in sectors at risk could be identified in an appendix to the policy. As for the section on performance measurement, successive inspections will show whether there has been any improvement in OHS in workplaces, which, in general, are under the responsibility of clearly defined positions. On this basis, managers should be able to assess performance.

Discussions should be begun between the OHS committees and HR to reach consensus on the actions to be taken to fulfil this recommendation.

4. Is dealt with in point 3 above.

B.2

That a method or system be instituted to ensure that the responsibilities assigned are in fact discharged. Add to the Manager's Handbook, for purposes of completing the performance evaluation, a text specifying the OSH elements to be evaluated (HR).

PHSC and LHSC

March 2003 (to be reviewed)

To be done

Discuss with HR to reach an agreement on how to proceed.

We are in agreement with this action.

Again, it should be noted that successive inspections in a given sector will enable us to assess whether responsibilities assigned to particular sectors/positions were in fact discharged.

C.0 Communications with management

C.1

That management communicate with employees at least once a year on the following subjects:

  • The importance of safety and health to everyone
  • The Agency's commitment to safety and health.

1. Annual news release during OHS Week in October

2. Suggest that an OHS recognition program be instituted. Set terms of reference and rules (HR and All)

3. Include an OHS item on the agenda of EC meetings and sectoral management meetings

4. Inform LHSC members and form a communications task force within the Committee

2. LHSC and/or PHSC

3. PHSC

1. Done

 

2. To do

 

 

3. In part

 


4. Done

1. Done via email:

  • Due diligence in September 2001
  • Statement in August 2001.

2. Human Resources are willing to have an award instituted but say the necessary action should be taken by LHSC or the PHSC and would be supported by them.

3. We found that the subject had been dealt with in sectoral management committees but the EC had not specifically addressed it. This action should be carried out by the Policy Committee, which, we have been told by the only member so far appointed to the Committee, should be in operation in 2003.

4. Was observed in the minutes.

C.2

That periodic inspections be done, at set times, depending on the management level.

These inspection tours should be verifiable and should involve specific observations on health and safety and discussions with workers.

1. Draw up a list of sectors

2. Draw up an inspection schedule

3. Form a communications task force, sensitize members to encourage them to participate in their sector's inspection tours with their directorate's management

2. PHSC

2003-2004

1. Done


2. To do


3. Done

1. List obtained

2. Discussed with the person in charge of the Policy Committee, will be done during the next fiscal year

3. Was observed in the minutes.

2. IDENTIFICATION AND MONITORING OF DANGERS

Health Canada recommendations Action plan Resources Deadline Follow-up audit AERD Comments
A.0 Inspections

A.1

That regular inspections of all sectors be done by a team made up of a manager (preferably the supervisor) and one or more employees.

1. Draw up a list of sectors and classify them by type of risk

2. Inspection team's training

3. Identify and involve sectorial supervisors

 

1. Done

 


2. Done

 

3. Done

1. The list of sectors to be inspected and deadlines have been established for 2001, 2002 and 2003.

2. Training in workplace inspection of persons involved in such inspections has been verified in the Continuous Learning Monitoring System (CLMS).

3. The name of the sectorial supervisor is shown in the list of sectors to be inspected and he or she is involved during the inspections. The name of the sectorial person involved is also shown on the inspection report.

A.2

That audit lists be developed for each work sector.

Each list should include, in particular:

  • Points to be checked
  • A summary description of the anomalies found
  • A description of actions to be taken to correct the anomalies
  • The name of the person responsible for making corrections
  • Expected date of correction of the anomaly
  • Follow-up of the corrective measure
  • Feedback to employees.

1. Identify where lists should be developed

2. Develop lists with supervisors and users

3. Develop a specific audit list for each workplace

4. Attach these lists to the workplace OHS plan

  • 1st inspection with managers / inspectors
  • Equip managers with tools so that they will be self-sufficient
  • Random audits, by inspectors, of inspection results
 

1. Done


2. Done


3. Done

 

4. In part

1. Lists were developed for laboratories and offices.

2. Same

3. Same

4. The first inspection is done by a LHSC member together with a sector representative. The next time, the inspection should be done by the sector's own people only (since we are at the beginning of the implementation of the inspection program, inspections by sectorial people only have not yet been observed).

B.0 Reports on dangers

B.1

That employees receive training in recognizing dangers.

1. Identify types of training vs dangers in sectors when workplace inspections are done by LHSC members.

2. Supervisors must identify training required and include this in the OHS plan.

3. Supervisors must establish a training schedule.

4. Obtain training data from HR.

 

1. Done

 

 


2. Done

 



3. Done


4. Done

1. The training required for specific risk activities is identified in the OHS plans.

2. Same

3. The training required is usually identified in the employee's performance appraisal report.

4. We obtained from HR a list of all OHS courses taken by Agency employees in 2001-02 and 2002-03.

B.2

That a process be implemented whereby danger declarations may be sent to those concerned and employees informed.

1. Inform the supervisor.

2. The supervisor assesses the danger (investigation).

3. Warn those employees concerned.

4. Take corrective action as required, as quickly as possible (with diligence).

5. Complete and send the form. (in accordance with Part II of the CLC, sect. 125, Duties of Employers).

 

1. Done


2. Done

 


3. Done

 

4. Done

 


5. Done

The "health and safety prevention notice" form, available on the Intranet, responds to all of these actions.

B.3

That a danger declaration form be developed, stating corrective measures to be taken, the turnaround time, the completion date, the signature of the person responsible, and the feedback date. This process should ensure effective follow-up. Development of a form   Done Form identified above: "safety and health prevention notice"

B.4

That a logbook be created so that all dangers not corrected the same day are recorded and followed up as required.

1. Development of a logbook

2. Institution of a follow-up system

 

1. Done

2. Done

1. A logbook of complaints / incidents / accidents / risks has been developed. It is filled in by hand but will be computerized soon, according to the OHS Officer.

2. The OHS Officer does a regular follow-up of pending items.

3. WORK RULES AND PROCEDURES

Health Canada recommendations Action plan Resources Deadline Follow-up audit AERD Comments
A.0 Safety rules

A.1

That safety rules be periodically reviewed at meetings

1. Safety rules shall be recorded in OHS plans and posted conspicuously in the workplace.

2. OHS promotion by the OHS representative at meetings between supervisors and employees.

 

1. In part

 

 

2. Done

1. OHS plans now exist in a number of sectors at risk but not in all sectors where plans are required; moreover, some plans date from 1994. Plans should be reviewed regularly.

2. LHSC representatives have told us (supported by minutes of sectorial meetings in some cases) that the OHS theme was discussed at management meetings in their sector.

A.2

That a method of verifying compliance with established rules be developed. Audit at the time of inspections annual; include managers' inspections in the report   Done Done at inspection time.

A.3

That a written rule be implemented on overindulgence in alcohol and drugs.     To do This element had not been shown in the recommendations. We added it. The upcoming policy should contain a note to that effect.
B.0 Normal work procedures

B.1

That procedures and codes of practice be drafted for all dangerous work or risky activities.

1. Identification of dangerous work and risky activities and integration into OHS plans.

2. Do research to identify minimal procedures.

3. Personalize, adapt and complete procedures on dangerous work and risky activities, integrate these into the OHS plans and communicate them to employees.

Sectorial representatives on LHSC

December 2003

In part

Ongoing

OHS plans exist already for many, but not all, risky locations. Development is proceeding normally. Some plans should be updated (date from 1994 and 1997). Others need to be developed. When they are available, the plans are posted on the bulletin board at the entrance to the premises in question.

B.2

That employees participate in the development and updating of procedures and codes of practice.

1. Ensure that identification of dangerous work and risky activities and development of procedures is done in consultation with employees.

2. Consultation and support of Health Canada.

Sectorial representatives on LHSC

December 2003

In part

Ongoing

Same as previous item. Moreover, the list of risky locations should be updated, because, at the time of our tour with the OHS Officer, we noted that some locations were not on the list.

The OHS Officer told us that a binder system would be implemented soon. This binder would contain all relevant information on an at-risk sector (OHS plan, training, inspections, WHMIS sheets, etc.) and would be kept at the entrance to each of the sectors concerned, on a stand, to ensure it is visible and available for consultation.

C.0 Individual protection equipment

C.1

That individual protection equipment be stored neatly.

1. Identify concrete problems

2. Provide storage cupboards where necessary

3. User awareness program to be implemented

4. Integrate audit into weekly inspections

 

1. Done

 

2. Done

 


3. Done

 


4. Done

1. In fact, there was a problem in the machine shop.

2. Storage cupboards are available for equipment.

3. During inspections, employees and managers are made aware of this.

4. Supervisors see to the proper maintenance of equipment during their weekly inspections.

D.0 Implementation

D.1

That CSA adopt a disciplinary policy for anyone violating its safety rules.

This policy should be communicated to all employees, posted in workplaces and included in the orientation session (introduction).

1. Include disciplinary measures in the OHS policy.

2. Based on TB disciplinary measures.

PHSC and LHSC

 

March 2003 - to be reviewed

To come This concept will be included in the upcoming OHS policy.
E.0 Emergency procedures

E.1

That a logbook be included in each first aid kit.

1. Develop a logbook and include it in each kit.

2. Train and sensitize first aid personnel to the importance of filling out the logbooks.

3. Implement a logbook collection process.

4. Compile data for reports.

 

1. Done

 


2. Done

 

 

3. Done

 

4. Done

1. The logbook has been seen.

Our review indicated that in general, the logbook was included in the kit in office areas, but not invariably in program areas (laboratories).

A follow-up should be done when kit materials are renewed.

2. The logbooks we saw in the kits were not filled out. Apparently, the inventory does get renewed from time to time, but no entry is made in the logbook when materials are used.

A reminder should be issued of the importance of filling out the logbook.

3. The logbook in the first aid room (security area) is collected regularly according to the OHS Officer, but not those on the floors (which are hardly used, if at all).

The annual report gives a rundown of cases reported.

4. TRAINING

Health Canada recommendations Action plan Resources Deadline Follow-up audit AERD Comments
A.0 Safety orientation sessions

A.1

That an orientation session be organized focusing, in particular, on occupational health and safety, such as:

  • Policies and procedures
  • Safety and health instructions
  • Responsibilities inherent in the job
  • Regulatory requirements
  • Workers' right to be aware of, and to refuse, unsafe work

1. Complete OHS policy and procedures (ADM/HR).

2. Develop the welcome kit.

3. Inform/train managers on the contents and use of the kit.

4. Ensure that managers attend orientation sessions; verification with employees.

5. To begin with, when orientation sessions are being held, send managers a memo on basic OHS rules.

LHSC orientation task force

1. March 2003

 


3. to 5. June 2003

1. To do

 

2. Done

 

3. To do

 

 

4. To do

 

 

 

5. To do

On March 13, 2003, the first orientation session was held for new employees. It was organized by HR, with contributions from each of the sectors concerned.

LHSC provided OHS information. This ought to be included in the kit issued to participants at the next orientation sessions.

The OHS Officer was also given a 15-minute time slot to make an OHS presentation.

A.2

That discussions be held, right from a new employee's first day of work, on such important things as:

  • Emergency procedures
  • The alarm system
  • Danger reports
  • Incident / accident reports

1. When issuing and explaining the documentation on emergency measures and on alarm systems, add documentation and explanations on danger reports and incident/accident reports (ADM).

Awareness form: to be read by the supervisor and signed by the employee upon arrival and reviewed at the time of the annual performance appraisals.

2. Ensure that supervisors discuss these matters with new employees.

LHSC orientation task force

June 2003

1. In part

 

 

 

 

 

 

 

 

 

 

2. To do

1. See above - orientation session. Also determine how signed forms are to be collected.

 

 

 

 

 

 

 


2. Signed forms will make sure employees actually receive the information.

A.3

That an orientation session be developed, specifically for health and safety, for contractors (employees of companies under contract) and visitors.

1. For employees of companies under contract: when the kit is issued. Awareness form, to be read by the contract authority and signed by the contractual upon arrival.

2. For visitors: develop a leaflet containing information on CSA's OHS policy; this leaflet would be distributed at the reception desk, upon registration.

LHSC orientation task force

1. March 2003

 

 

 

2. June 2003

1. To do

 

 

 

 


2. To do

1. Determine how signed forms are to be collected.

 

 

 


2. Under development.

B.0 On-the-job training

B.1

That partial training be completed and kept up to date

1. Required training to be identified in workplaces' OHS plans.

2. Check during annual inspections whether necessary training was properly identified and actually taken.

3. Check in training database (HR).


4. To be included in the annual report.

 

1. Done

 

 

2. Done

 

 


3. Done

 

 

4. Done

1. Identified in OHS plans.

 


2. Information on training will be included in the binder referred to in 3.B.


3. Training given in 2001-2002 and 2002-2003 has been identified through CLMS.

4. The 2002 annual report reflects training taken during the year.

B.2

That employees handling chemicals receive WHMIS training

1. Schedule WHMIS training for the second week in May so as to include summer students.

2. Make managers aware in advance of candidates for training.

 

1. Done

 

 

2. Ongoing

1. The list of employees holding a WHMIS certificate was reviewed.

In four cases, the certificates had expired. In such cases, check whether training is still required.

2. Continuous process

B.3

That a continuous training program be implemented as required.

1. Supervisor identifies required training.

2. Training program to be implemented by supervisor.

3. Produce up-to-date lists from the HR training database for the OHS Officer's annual report

 

1. Ongoing


2. Ongoing

 

3. Ongoing

1. Training is identified in the OHS plan.

2. Training for each employee is identified in the performance appraisal report.

3. Information on training taken during the year may be compiled from CLMS and is then presented in the annual OHS report.

5. TRAINING

Health Canada recommendations Action plan Resources Deadline Follow-up audit AERD Comments
A.0 Communications system

A.1

That the health and safety communications system be improved. To be effective, the system must allow workers to contribute to it freely and receive feedback. We also refer you to the recommendations in section 1.C.0 of this report.

1. Improve the OHS intranet site.

2. Include a Q&A; section on the intranet with a direct access button on the intranet homepage.

3. Place OHS discussions on the agenda of sectorial management meetings.

4. Implement a dedicated task force on OHS communications.

 


2. LHSC task force on communications

June 2003

1. Done


2. To do

 

 


3. Done

 

 

4. Done

1. Intranet site developed.

2. To come

3. Done, according to our discussions (supported by minutes in some cases) with representatives of LHSC member sectors.

4. Meeting minutes attest to the creation of the task force on communications (in particular minutes of the November 29, 2002 meeting)

A.2

That the internal publication Capsule regularly report on occupational health and safety. The OHS committee should make sure that an article appears in each issue of Capsule.

 

Done Articles published in Capsule: Who does what - Summer/Fall 2001 and Ergonomics - Winter 2002.

A.3

That Departmental meetings periodically deal with safety and health subjects and enable feedback to be received on the problems raised.

1. Place OHS discussions on the agenda of sectorial management meetings.

2. Reminder from the Policy Committee to the Executive Committee.

3. The sector's representative on LHSC should raise OHS points for his or her sector at management meetings.

 

 

 

2. PHSC

2003-2004

1. Done

 

 

2. To do

 

3. Done

1. Done, according to our discussions (supported by minutes in some cases) with representatives of LHSC member sectors.

2. The Policy Committee will be set up soon and will be assigned this task.

3. Same as item 1.

B.0 Safety meeting

B.1

That tighter deadlines be set so that corrective measures can be taken more quickly.

1. Progress of follow-up and other progress should be reflected in minutes.

2. Promote target dates for corrective measures.

 

1. Done

 



2. Done

A follow-up table has been implemented, with target dates for each of the corrective measures.

B.2

That guidelines be implemented to organize health and safety meetings in the departments. The sector's representative on LHSC should raise OHS points for his or her sector at management meetings.

 

Done Done, according to our discussions (supported by minutes in some cases) with representatives of LHSC member sectors.

B.3

That guidelines be implemented to organize meetings with contractuals and subcontractors. To be developed

LHSC orientation task force

June 2003

To do The orientation task force plans to look at this by June 2003. (See also 4.A.3.)

6. INCIDENT AND ACCIDENT REPORTS AND INVESTIGATIONS

Health Canada recommendations Action plan Resources Deadline Follow-up audit AERD Comments
A.0 Incident and accident report

A.1

That a written policy be implemented indicating that all incidents / accidents and near accidents must be reported.

1. To be recorded in general OHS policy.

2. Include all of this in the kit issued upon arrival.

1. Policy OSH Committee and LOSHC

March 2003 - to be reviewed

2. LHSC orientation task force

June 2003

1. To do

 

 

2. To do

1. Will be included in the policy.

2. Should be included in the kit for new employees attending orientation sessions subsequent to the one on March 2003.

A.2

That an incident/accident report form be used that includes written instructions on how to fill it out Develop an incident report form.

 

Done

The same form is used as at Labour Canada.

We added part of the recommendation that had been forgotten: "with written instructions on how to fill it out".

The written instructions on how to fill out the form are on the back of it.

B.0 Incident and accident investigations and follow up

B.1

That investigators receive training on investigation technique and accident analysis.

1. Training of OHS officer.

2. Training of all LHSC members.

3. Identification, awareness and training of supervisors.

LHSC training task force

1. To be determined

2. June 2003

3. Ongoing

1. To do

2. To do

 

3. Ongoing

1. A training course in investigation and accident analysis had been set for May 2002 but had to be postponed. Follow up the action plan with respect to this training.

2. Same as item 1.

3. According to discussions with the OHS Officer, awareness sessions and supervisory training are done when the sectors are inspected.

B.2

That investigations be done for all incidents, accidents and near accidents

1. Draw up an investigation reporting mechanism.

2. Encourage reporting of incidents/accidents.

3. Follow up recommended corrective measures.

 

1. Done

 

2. Done

 

3. Done

1. A system is in place for the reporting of all incidents to the OSH Officer, who follows up until these are resolved.

2. This is an ongoing process.

Top of page

APPENDIX 2 – ACTION PLAN ARISING FROM THE AERD FOLLOW-UP AUDIT

Ref.
Recommendation
Responsibility Identified Details of Action Plan Timetable
Organization Action by
2.1 Actions involving the policy committee

That a PHSC be established and work with LOSHC to determine their respective roles and responsibilities, since both committees are closely concerned with the management of the OHS Program.

A number of actions planned in response to the recommendations in the Health Canada report call for co-operation between the PHSC and the LOSHC.

PHSC

 

 

 

 

 

 


LHSC

Jacques Lachapelle

 

 

 

 

 

 

Yves Guindon

In agreement. The first meeting of the PHSC took place on April 24, 2003.

In June, the chairman of the PHSC will be undertaking a consultation w ith the LHSC to canvass the latter's views on the respective roles of the two committees and prepare for discussions at the PHSC meetings in June and September.

In agreement.

April 2003

 

 

June and September 2003

2.2 Actions involving the human resources directorate

1.B.1 That the planned action be reviewed to comply with this Health Canada recommendation and to achieve consensus between all concerned. No matter which option is chosen, it should be acceptable to all concerned, and an implementation timetable should be set.

PHSC

 

 

 

 

 

 

 


LHSC


HRD

Jacques Lachapelle

 

 

 

 

 

 

 

Yves Guindon

M. Symonds

In agreement. Discussions on this matter will take place at the next PHSC meeting and the various options preferred by the parties involved will be identified.

It should be noted that a management representative from human resources sits on PHSC.

The implementation date has yet to be determined; it will depend on the option chosen by the parties.

In agreement.

In agreement. It is our view that the ultimate goal, namely to enhance management awareness and commitment to OHS, will be better served by involving CSA's EC rather than by systematically adding an OHS statement to work descriptions for at-risk sectors of CSA.

In addition, since the points at issue have implications that go beyond CSA, it is suggested that LHSC refer this item (the addition of OHS concepts to work descriptions) to TBS resource persons to determine what is generally done or what ought to be done in this area in all departments.

June 2003

 

 


Date to be confirmed

1.B.2 That the LHSC and the PHSC embark on discussions with the HR Directorate to reach an agreement on how to implement this action.

PHSC

 

 

 

LHSC


HRD

Jacques Lachapelle

 

 


Yves Guindon

M. Symonds

In agreement. This point will be discussed at the September 2003 PHSC meeting.

The implementation date has yet to be determined; it will depend on the outcome of the discussions.

In agreement.

In agreement. Even if an OHS statement is added to work descriptions, that does not necessarily mean that OSH becomes a consideration for performance appraisal, unless it is added as a priority and performance is appraised accordingly; but CSA's Executive Committee, not the Human Resources Directorate, is responsible for setting priorities of this type.

In view of the foregoing, it is suggested that the LHSC and PHSC submit to the Executive Committee for approval the OHS performance objectives to be included in work descriptions if they wish these to be included systematically in the performance appraisals of employees working in at-risk sectors.

September 2003

 

Date to be confirmed

1.C.1 That the LHSC and the PHSC reach an agreement with the HR Directorate on how to implement this action.

PHSC

 

 

 

 

 

 

 

LHSC


HR

Jacques Lachapelle

 

 

 

 

 

 


Yves Guindon

M. Symonds

In agreement. The various ways of enhancing occupational safety and health will be discussed at the October 2003 PHSC meeting. PHSC believes that enhancing OHS is a good idea. An enhancement mechanism should be determined in October 2003.

The implementation date for this mechanism will be determined depending on the decision made in October 2003.

In agreement.

In agreement. It is suggested that the LHSC and the PHSC use the documentation that has already been provided to them if they wish to update the idea of instituting an OHS recognition program. If the OHS committees need additional information, the Human Resources Directorate management resource person for that is Stéphanie Charron.

October 2003

 

 

 

 

Date to be confirmed

2.3 Other actions called for in the plan
Review the proposed March 2003 deadline for development of an OSH policy.

PHSC


LHSC

Jacques Lachapelle

Yves Guindon

In agreement. At its September 2003 meeting, PHSC will look at the need for an OSH policy in addition to the Canada Labour Code.

September 2003

 

Updated: 2004/05/31 Important Notices