2014-2015 Audit of Occupational Health and Safety

December 3, 2015

2014-2015

Agriculture and Agri-Food Canada - Office of Audit and Evaluation

Executive summary

The Government of Canada protects workplace safety through legislation, programs and services designed to prevent accidents and injuries on the job. Health and Safety Officers, with the Employment and Social Development Canada– Labour Program monitor compliance with and enforce health and safety requirements of the Canada Labour Code - Part II legislation and the Canada Occupational Health and Safety Regulations while promoting and applying health and safety practices.

In addition, Agriculture and Agri-Food Canada's (AAFC's) Occupational Health and Safety (OHS) activities are also governed by requirements included in AAFC's Policy Concerning the Occupational Health and Safety of Employees and various other directives and guidelines that have been developed within AAFC's Hazard Prevention Program. As a part of this Program, AAFC has established a set of mandatory training courses for occupational health and safety.

In 2013-2014, one of the Department's human resources priorities and key activities was to implement a healthy and safe workplace framework. Strategies and initiatives included among other things, increasing OHS training to managers and employees, implementing a centralized approach to managing work-related injury and illness (e.g. Workers' Compensation) and establishing external service contracts to deliver an Employee Assistance Program and Duty to Accommodate services.

The audit of OHS was approved by the Deputy Minister in the Agriculture and Agri-Food Canada Risk-Based Internal Audit Plan for fiscal years 2014-2017.

The objective of this audit was to provide assurance on the adequacy and effectiveness of the management control framework employed by AAFC in support of compliance with the Canada Labour Code - Part II and related regulations.

As the audit scope focused on management control activities in support of compliance with the Canada Labour Code - Part II, it did not constitute a technical review of OHS.

The audit team noted that the Department has a comprehensive set of policies, directives and program instruments to guide OHS management at AAFC.

Internal Audit identified that oversight at the local level is implemented and adequate. Oversight weaknesses were observed in the management control framework for the AAFC National OHS program. Audit recommendations are addressed to the Assistant Deputy Minister (ADM), Corporate Management Branch (CMB) in the areas of: Monitoring, Reporting, Policies and Programs and Training.

Recommendations have been included in this report to address the weaknesses identified.

1.0 Introduction

1.1 Background

• 1.1.1 The Government of Canada protects workplace safety through legislation, programs and services designed to prevent accidents and injuries on the job. Health and Safety Officers, with the Employment and Social Development Canada - Labour Program monitor compliance and enforce health and safety from the Canada Labour Code - Part II legislation and the Canada Occupational Health and Safety Regulations while promoting and applying health and safety practices.
• 1.1.2 Employment and Social Development Canada requires that a workplace develop, implement and monitor a program for the prevention of hazards. As such, Employment and Social Development Canada has developed a Hazard Prevention Program Guide from the Canada Labour Code - Part II legislation to assist employers in the development and monitoring of their Hazard Prevention Programs. Key components of a hazard prevention program include:
  • implementation plan;
  • hazard identification and assessment methodology;
  • hazard identification and assessment;
  • preventative measures;
  • employees education; and
  • program evaluation.
• 1.1.3 Agriculture and Agri-Food Canada (AAFC) is committed to providing a healthy and safe working environment for all its employees, regardless of tenure or status. The Department promotes occupational health and safety (OHS) as an integral part of its corporate culture, and integrates OHS into its management and business decision-making processes.
• 1.1.4 AAFC is a medium-sized department with approximately 5,000 employees with the majority of employees working in the regions across the country. The diversity of occupational groups employed within the Department reflects AAFC's dependence on a broad range of skills in science, policy, programs, markets and trade, and operations. AAFC employees carry out their work duties in four main types of work environments: farms/pastures, maintenance facilities, laboratories and offices. The largest branch within AAFC is the Science and Technology Branch (STB), representing approximately 44% of the workforce^{Footnote 1}.
• 1.1.5 AAFC OHS activities are also governed by additional requirements such as AAFC's Policy Concerning the Occupational Health and Safety of Employees and various other directives and guidelines that have been developed within AAFC's Hazard Prevention Program as preventive measures. In addition, as a part of this Program, AAFC has established a set of mandatory training courses for occupational health and safety.
• 1.1.6 In 2013-2014, one of the Department's human resources priorities and key activities was to implement a healthy and safe workplace framework. Strategies and initiatives included among other things, increasing OHS training to managers and employees, implementing a centralized approach to managing work-related injury and illness (e.g. Workers' Compensation) and establishing external service contracts to deliver an Employee Assistance Program and Duty to Accommodate services.
• 1.1.7 The OHS management control framework is mainly decentralized. AAFC's senior management, managers and supervisors have specific OHS responsibilities which they are expected to carry out to ensure the safety of staff, visitors, students and contractors in their area of responsibility. Corporate Management Branch is responsible for the management of the National Occupational Health and Safety Program. The program falls under the Human Resources Directorate and the Workplace Wellness Programs Division (which reported under the Labour Relations Division prior to April 2015) within the Departmental organizational structure. Regional OHS Coordinators provide advice and guidance on OHS and administratively report to an Associate Director, Research Development and Technology in the Science and Technology Branch.

• 1.1.8 The AAFC OHS structure^{Footnote 2} is as follows:

  

  The table illustrates the Occupational Health and Safety structure. The contents of the table are as follows:

  Corporate Management Branch:
  Corporate Management Branch oversees HR Directorate / Workplace Wellness Programs; HR Directorate / Workplace Wellness Programs oversees National Occupational Health and Safety Program; National Occupation Health and Safety Programs oversees both National Occupational Health and Safety Program Team Manager and Regional Occupational Health and Safety Coordinator (National Capitol Region); National Occupational Health and Safety Program Team Manager oversees Occupational Health and Safety Project Officer.

  Science and Technology Branch:
  Science and Technology Branch oversees Ecozone Research Centres and Cross-Sectoral Strategic Directorate; Ecozone Research Centres oversees Director, Research, Development and Technology (RDT); Director, Research, Development and Technology (RDT) oversees Associate Director, RDT; Associate Director, RDT oversees Regional OHS Coordinators (8) and Lab Technicians/Coordinators. Cross-Sectoral Strategic Directorate oversees Integrated Planning and Reporting; Integrated Planning and Reporting oversees Departmental Radiation Safety Officer/Advisor.

  Programs Branch:
  Programs Branch oversees Community Pastures Program – Land Management Unit and Farm Income Program Directorate – BRM Financial and Administrative Services; Community Pastures Program – Land Management Unit oversees Health and Safety Training Officer; Farm Income Program Directorate – BRM Financial and Administrative Services oversees Security, Health and Safety Officer.

  National Occupational Health and Safety Program Team Manager is connected to the National Occupational Health and Safety Policy Committee.

  Regional Occupational Health and Safety Coordinator (National Capital Region) is connected to the Health and Safety Training Officer and Security, Health and Safety Officer.

  Regional Occupational Health and Safety Coordinators (8) and Lab Technicians/Coordinators are connected to Work Place Health and Safety Committees or Health and Safety Representative.

  Departmental Radiation Safety Officer/Advisor is connected to National Radiation Safety Committee.

  National Occupational Health and Safety Policy Committee; Work Place Health and Safety Committees or Health and Safety Representative; National Lab Safety Committee; National Radiation Safety Committee; and National Containment, Biosafety and Biosecurity are connected to each other.

• 1.1.9 The audit of OHS was approved by the Deputy Minister in the Agriculture and Agri-Food Canada Risk-Based Internal Audit Plan for fiscal years 2014-2017.

  Note: For ease of reference, throughout this report the Departmental Policy Concerning the Occupational Health and Safety of Employees will be referred to as the AAFC OHS Policy.

1.2 Audit objective

• 1.2.1 The objective of this audit was to provide assurance on the adequacy and effectiveness of the management control framework employed by AAFC in support of compliance with the Canada Labour Code - Part II and related regulations.

1.3 Audit scope

• 1.3.1 The audit scope focused on management control activities in support of compliance with the Canada Labour Code - Part II, it did not constitute a technical review of OHS.
• 1.3.2 The scope covered activities within the Department and included:
  • Interviews to assess the administration of the OHS program at the national and local level;
  • Review of documentation and analysis of management controls, monitoring and reporting practices related to OHS; and
  • Review of the work safety program manuals and related tools. Subject-matter-experts were consulted as a part of this review.
• 1.3.3 The risk assessment identified the following lines of enquiry for review during the audit (Annex A):
  • Oversight, roles, responsibilities and accountabilities
    1.1 An oversight structure is established and OHS roles, responsibilities, accountabilities and authorities are clearly defined, communicated and implemented to ensure effective oversight and successful implementation of the OHS program.
  • Training, tools and awareness
    2.1 Employees and non-employees are trained in support of legal requirements of OHS and in a timely manner.
  • 2.2 OHS training and awareness programs and supporting tools are established, delivered, monitored and updated to ensure the health and safety of workplaces.
  • Policies and programs
    3.1 AAFC's policies, guidelines and processes related to OHS are implemented, monitored, updated on a regular basis and align with relevant laws and regulations.
  • Reporting and monitoring
    4.1 Formal OHS reporting and monitoring mechanisms are established, implemented and accurate to ensure AAFC's OHS program is in compliance with legal requirements.

1.4 Audit approach

• 1.4.1 The approach and methodology used for the audit was consistent with the Internal Audit standards as outlined by the Institute of Internal Auditors and aligned with the Treasury Board Internal Auditing Standards for the Government of Canada.
• 1.4.2 Audit criteria were selected from the Canada Labour Code - Part II, Employment and Social Development Canada Labour Program guidelines, Canadian Occupational Health and Safety Standards and AAFC OHS Policy and other relevant AAFC OHS documentation.
• 1.4.3 A risk-based audit program was developed that defined audit tasks to assess each audit criterion. Audit evidence was gathered through various methods including interviews, observations, documentation review and analysis.
• 1.4.4 The audit's conduct phase took place from December 2014 to June 2015 and included a review of the most recent management practices and processes in place. Sampling documentation was requested from the period from September 2013 to June 2015.

1.5 Conclusion

Internal Audit identified that oversight at the local level is implemented and adequate. Oversight weaknesses were observed in the management control framework for the AAFC National OHS program. Audit recommendations are addressed to the Assistant Deputy Minister (ADM), Corporate Management Branch (CMB) in the areas of: Monitoring, Reporting, Policies and Programs and Training.

Recommendations have been included below to address the weaknesses identified.

1.6 Statement of conformance

• 1.6.1 In the professional judgment of the Chief Audit Executive, sufficient and appropriate audit procedures have been conducted and evidence gathered to support the accuracy of the conclusion provided and contained in this report. The conclusion is based on a comparison of the conditions, as they existed at the time and against pre-established audit criteria that were agreed on with management. The conclusion is applicable only to the entity examined.
• 1.6.2 This audit conforms to the Internal Auditing Standards for the Government of Canada, as supported by the results of the quality assurance and improvement program.

2.0 Detailed observations, recommendations and management responses

• 2.0.1 During the conduct of the audit, the Internal Audit team observed that the organizational and governance structures are established to oversee Occupational Health and Safety (OHS) activities at both a local level by way of the Workplace OHS Committee and the Regional OHS Coordinator and at a national level by way of the National OHS Program Policy Committee and the National OHS Program. Internal Audit observed that key oversight documents are established and align with Canada Labour Code requirements.
• 2.0.2 Minutes of committee meetings and results of interviews indicate that local and national committee members demonstrate a high level of dedication in addressing OHS issues.
• 2.0.3 The section below presents the key observations, based on the evidence and analysis associated with the audit, and provides recommendations for improvement.
• 2.0.4 Management responses are included and provide:
  • an action plan to address each recommendation;
  • a lead responsible for implementation of the action plan; and
  • a target date for completion of the implementation of the action plan.

2.1 Monitoring

• 2.1.1 The Employment and Social Development Canada Hazard Prevention Program Guide^{Footnote 3} requires that the employer shall monitor the progress of the implementation of Hazard Prevention Programs and that the evaluation of program effectiveness should be conducted at least every 3 years.
• 2.1.2 In addition, the Agriculture and Agri-Food Canada (AAFC) OHS Policy states that AAFC will achieve a healthy and safe working environment through development, implementation and monitoring of a Hazard Prevention Program encompassing the elements of a hazard identification process.

Hazard identification and risk assessment

• 2.1.3 Employment and Social Development Canada requires that employers develop a Hazard Prevention Program based on a documented methodology for hazard identification and risk assessment.
• 2.1.4 Employment and Social Development Canada further requires that the methodology considers inputs and factors that include among others: hazardous occurrence reports, workplace inspection results, time lost due to injury and also requires the review and updating of the methodology on a regular basis.
• 2.1.5 A Hazard Risk Registry document was developed in 2007 outlining the risks associated with AAFC business activities. However, the risk registry has not been updated and interviews indicated that the document was developed using subjective methodology without a documented process. Further, it is not used to guide the program development or National OHS Program activities.
• 2.1.6 Trend analysis at the local workplace level is informal with Workplace OHS Committees indirectly monitoring OHS primarily via workplace inspections and the review of Hazardous Occurrence Incident Reports. As well, Regional OHS Coordinators are generally in attendance at Workplace OHS Committee meetings or receive a copy of the meeting minutes. If a trend is identified, it may be verbally shared at the national level.
• 2.1.7 Internal Audit identified that hazardous occurrence and training information was previously provided to the National OHS Policy Committee for decision making, however, this information was found to be incomplete and erroneous (see section 2.3). As such, the National OHS Policy Committee did not receive accurate information required to identify, assess, respond to and monitor OHS risk at local level.
• 2.1.8 The National OHS Program does not conduct formal trend analysis to guide national program development and feed into the work plan of the National OHS Program.
• 2.1.9 Without a documented methodology for hazard identification and risk assessment process, there is the potential risk that the Hazard Prevention Program will not focus on the areas of highest risk.

Assessment of hazard prevention program implementation

• 2.1.10 The National OHS Program created a database in fall 2014 to capture Workplace OHS Committee information such as the OHS policies and programs that have been locally implemented. The database was expected to be populated by all research centres as of March 2015. The National OHS Program management selected research centres at highest risk to first populate the database.
• 2.1.11 In June 2015, the National OHS Program management advised that not all branches had provided input and that management had not developed a plan to review/assess and follow-up on information populated in the database. As well, the National OHS Program management did not plan to extend the request beyond the high risk locations.
• 2.1.12 While the database does not currently address the regulatory requirements for the assessment of Hazard Prevention Program implementation, a well maintained and monitored database has the potential to provide National OHS Program management with the information necessary to assess policy and program implementation at the local levels on an ongoing basis.
• 2.1.13 At the time of the audit, aside from the database noted above, the National OHS Program did not have a mechanism in place to assess and monitor implementation of the Hazard Prevention Program across AAFC to meet the requirements of Employment and Social Development Canada and AAFC.

National OHS program 5 year plan

• 2.1.14 Work activities are planned by the National OHS Program for a 5 year period and are documented in the '5 Year Plan'.
• 2.1.15 Internal Audit reviewed the current version of the plan and observed that the current plan includes a more comprehensive review of policies than its previous version. However, the review is planned 4 to 5 years from the last review as opposed to the 3 year requirement established by Employment and Social Development Canada. The audit team also noted that the current '5 Year Plan' did not include review of all the policies, directives and programs in the established Hazard Prevention Program.
• 2.1.16 As per interviews conducted and the review of documentation provided to the audit team, the development of the '5 Year Plan' is not developed based on an assessment of risk within AAFC workplaces but rather informal input from AAFC OHS employees.
• 2.1.17 At the time of the audit the '5 Year Plan' was not disseminated to local Workplace OHS Committees to communicate the activities of the National OHS Program and to reduce the likelihood of a duplication of effort by the workplace committees.

• 2.1.18 Recommendation

  1. In order to comply with Canada Labour Code regulations, the Assistant Deputy Minister (ADM), Corporate Management Branch (CMB) should:

  1. Develop a methodology for hazard identification and risk assessment.

     Management response:
     Agree

     Action plan:
     The ADM, CMB will develop and document a methodology used for analysis and assessment of all identified hazards and risks. The methodology will include identifying both known and foreseeable hazards and will be based on a Health and Safety Risk Identification and Management Methodology.

     Lead(s) responsible:
     Director, Workplace Wellness Programs

     Target date for completion:
     September 2016

  2. Implement a process to conduct regular assessment (at least every 3 years) of the implementation of the Hazard Prevention Program at the local level (Workplace OHS Committee and Health and Safety Committees).

     Management response:
     Agree

     Action plan:
     The ADM, CMB will establish a process for the review of the implementation of the Hazard Prevention Program across Agriculture and Agri-Food Canada every 3 years. The results of the assessment will be a standing item on the Regional OHS Coordinator meetings and presented quarterly at the National OHS Policy Committee.

     Lead(s) responsible:
     Director, Workplace Wellness Programs

     Target date for completion:
     January 2016

  3. Establish a plan for the National OHS Program that includes the review of existing components of the Hazard Prevention Program such as directives/guidelines every 3 years and includes the development of new directives and guidance based on the hazard identification and risk assessment process.

     Management response:
     Agree

     Action plan:
     The ADM, CMB agrees to create a 3 year Hazard Prevention Program work plan that includes a cyclical review of all components of the Hazard Prevention Program. Following the implementation of recommendation 1a, this 3 year plan will also include the development of new directives, policies and guidelines based on the analysis and risk assessment identified in section 1a.

     Lead(s) responsible:
     Director, Workplace Wellness Programs

     Target date for completion:
     Develop 3 Year Plan for review of Hazard Prevention Program components by December 2015. Update plan to include development of new directives, policies and guidelines by October 2016.

2.2 Policies and programs

• 2.2.1 Employment and Social Development Canada requires that workplace Hazard Prevention Programs include preventative measures such as policies, directives, guidelines and processes based on hazards identified within the workplace.
• 2.2.2 Internal Audit reviewed whether AAFC's policies, guidelines and processes related to OHS are implemented, monitored, updated on a regular basis and aligns with relevant laws and regulations.
• 2.2.3 The audit team noted that the Department has a comprehensive set of policies, directives and program instruments to guide OHS management at AAFC.
• 2.2.4 As noted above in the monitoring section (section 2.1), there is no hazard identification process or risk assessment in place to determine or assess whether polices and program developed and implemented are appropriate. Interviews stated that policies are developed on a reactive basis and are not based on risk.
• 2.2.5 Internal Audit also reviewed whether directives were developed by the National OHS Program in a timely manner and observed a lack of timely development (more than one year) of key directives released during the conduct of the audit. In interviews with members of the National OHS Program, the audit team was advised that the delay in development was due to the number of individuals involved in the review and approval of these directives.
• 2.2.6 In an effort to determine whether the key directives released in early 2015 were compliant with the Canada Labour Code - Part II regulations and general best practices, Internal Audit contracted a Subject Matter Expert to review the documentation. Following the review, the Subject Matter Expert deemed that the directives are compliant with the Canada Labour Code - Part II.
• 2.2.7 Internal Audit determined that at a national level, there is no listing of the directives and/or programs that have been developed and are in place at local AAFC workplaces. This information would assist the National OHS Program in planning and in the development of future directives by leveraging information that already exists.
• 2.2.8 Workplace OHS Committee members interviewed across the Department commented that there has been a lack of communication of National OHS Program activities on the development of national directives. Due to delays in the development of the directives at the national level, workplace committees developed directives locally, resulting in a duplication of efforts and potentially a lack of consistency within AAFC.

• 2.2.9 Recommendation

  2. ADM, CMB should review the development and approval process for national directives to ensure timely development.

  Management response:
  Agree

  Action plan:
  The ADM, CMB will review the current process for the consultation and approval of national directives, programs and policies using the Lean Process Methodology. The new process developed will allow for a more streamlined process with fewer steps than the current process, thereby ensuring the timely development of national OHS directives. The process review and development will include the creation of a working group including key stakeholders from CMB, Science and Technology Branch (STB) and the National OHS Policy Committee.

  Lead(s) responsible:
  Director, Workplace Wellness Programs

  Target date for completion:
  October 2016

2.3 Reporting to regulatory bodies

• 2.3.1 In the event of hazardous occurrences in the workplace, Employment and Social Development Canada has established a process and timelines for documenting and reporting the details of the incident. All accidents, occupational diseases and other hazardous occurrences affecting any of the employer's workers must be investigated by a qualified person who must record the details of the incident on a Hazardous Occurrence Incident Report template. Reports are presented at the Workplace OHS Committee (and signed-off by committee co-chairs) to review the nature of the occurrence and identify whether mitigating measures are required.
• 2.3.2 Employment and Social Development Canada has defined the type of incidences which require the Hazardous Occurrence Incident report to be sent to Employment and Social Development Canada as follows:
  • Minor injury: Any employment injury or an occupational disease for which medical treatment is provided and excludes a disabling injury [Note: Medical treatment is that which is provided at a medical treatment facility, which means at a hospital, medical clinic or physician's office at which emergency medical treatment can be dispensed and is not to be confused with first aid.]
  • Disabling injury: Any employment injury or an occupational disease that results in either time loss, or modified duties. Disabling injuries can be either temporary (e.g. sprained wrist), or permanent (e.g. severed limb), depending on whether or not the employee is expected to make a full recovery.
  • Loss of consciousness: From an electric shock or a toxic or oxygen deficient atmosphere.
  • Rescue / revival or other emergency procedures: Any incident that requires emergency procedures to be implemented, such as a hazardous substance spill, bomb threat or violence prevention procedure.
• 2.3.3 The Hazardous Occurrence Incident Report document is the first recording of occurrences and becomes the source of initial reporting to Employment and Social Development Canada. It is also subsequently used in the annual workplace committee reporting to Employment and Social Development Canada that summarizes individual Hazardous Occurrence Incident Report information for both the Workplace OHS Committee and departmentally.
• 2.3.4 Once completed, Hazardous Occurrence Incident Reports are sent to Employment and Social Development Canada by the Workplace OHS Committee employer co-chair and are then sent to the Regional OSH Coordinator who is responsible to enter the occurrence information from the Hazardous Occurrence Incident Report into a departmental database.
• 2.3.5 Occurrences that do not require medical treatment do not need to be individually reported to Employment and Social Development Canada, however, the fact that an investigation was conducted is required to be reported to Employment and Social Development Canada through the annual Workplace Committee Report.
• 2.3.6 The audit team reviewed Hazardous Occurrence Incident Reports from September 2013 to December 2014 to determine the accuracy of reporting to the regulator and noted evidence of erroneous (either over and/or under) reporting of minor and/or disabling injuries to Employment and Social Development Canada. Accurate reporting to the regulator is important to ensure that mitigating measures are implemented in areas of highest risk.
• 2.3.7 Interviews with National OHS program management noted that the local workplace committees made errors in reporting because they were unclear about the types of occurrences that required reporting to Employment and Social Development Canada.
• 2.3.8 The National OHS program management advised the audit team that they were aware of the reporting errors and had issued revised guidance to local Workplace OHS Committees in early 2015 to clarify how to complete the Employment and Social Development Canada forms. The guidance communicated how to report hazardous occurrences and provided clarification of the types of occurrences that require reporting to Employment and Social Development Canada. To help ensure the consistent application, the guidance also requested that the annual workplace committee reporting (summary of individual occurrences for the year) be submitted and reviewed by the Regional OHS Coordinator prior to submission to Employment and Social Development Canada.
• 2.3.9 By requesting that the annual workplace committee report be submitted and reviewed by the Regional OHS Coordinator prior to submission to Employment and Social Development Canada, the erroneous information has already been submitted to Employment and Social Development Canada by way of the Hazardous Occurrence Incident Report. As such, the Regional OHS Coordinator would only be reviewing the accuracy of numbers and of the information in the annual report against what has already been submitted to Employment and Social Development Canada and therefore could not influence the consistency of reporting.
• 2.3.10 Based on the above, it is the opinion of the audit team that the control weakness for the reporting errors has yet to be adequately mitigated and that the Regional OHS Coordinator should review the Hazardous Occurrence Incident Report prior to it being sent to Employment and Social Development Canada to ensure consistency with the National OHS Program guidance.

• 2.3.11 Recommendation

  3. ADM, CMB should review current reporting process to include a review of Hazardous Occurrence Incident Reports by the Regional OHS Coordinators prior to submission to Employment and Social Development Canada in an effort to improve consistency and accuracy of reporting across AAFC.

  Management response:
  Agree

  Action plan:
  The National OHS Program will update the current Hazardous Occurrence Incident Reports reporting process to ensure that all Hazardous Occurrence Incident Reports are sent to Regional OHS Coordinators for review prior to submission to Employment and Social Development Canada.

  Lead(s) responsible:
  Director, Workplace Wellness Programs

  Target date for completion:
  New process effective December 1, 2015 with documentation to be published January 2016.

2.4 Reporting

• 2.4.1 Employment and Social Development Canada requires that following the assessment of the Hazard Prevention Program, a formal report be prepared to document the results.
• 2.4.2 At the time of the audit, the National OHS Program did not report to an AAFC senior management committee to provide updates on the implementation of the Hazard Prevention Program and National OHS Program activities and achievements. The Director responsible for the National OHS Program provided informal updates to the responsible DG who then updated the ADM responsible for OHS.
• 2.4.3 As a best practice, an annual report that provides senior management with updates on the number of occurrences, complaints observed during the year, the identification of any trends and the achievements of the National OHS program would provide useful information for monitoring the effectiveness of the program.

• 2.4.4 Recommendation

  4. ADM, CMB should develop and present a report to AAFC senior management that, as a minimum, documents the results of the assessment of Hazard Prevention Program implementation, in compliance with Employment and Social Development Canada requirements.

  Management response:
  Agree

  Action plan:
  The ADM, CMB will develop an OHS Annual Report that will be presented at Directors General Management Committee and Departmental Management Committee. This report will include incidents, training and implementation of Hazard Prevention Program components. Report will be based on a calendar year to align with Employment and Social Development Canada reporting.

  Lead(s) responsible:
  Director, Workplace Wellness Programs

  Target date for completion:
  June 2016

2.5 Training

• 2.5.1 Employment and Social Development Canada provides limited guidance regarding employee training and simply states that the employer shall provide health and safety education to each employee.
• 2.5.2 As a part of the Hazard Prevention Program developed at AAFC, the National OHS Program has established a set of mandatory training courses for occupational health and safety. Training has been defined for Students, Employees, Supervisors, Executives, Occupational Health and Safety Committee Members and temporary employees working at AAFC for less than 6 months (including casuals, seasonal, terms less than 6 months, non-employees and student employees). Depending on the employee and their role, mandatory training may include multiple courses.
• 2.5.3 As per the AAFC OHS Policy, supervisors are responsible to provide employees with the information, instruction, training and supervision necessary to ensure their health and safety.
• 2.5.4 Internal Audit tested whether employees and non-employees are trained in a timely manner as per AAFC mandatory requirements, at the time of the audit.
• 2.5.5 AAFC relies on the collaboration of volunteers, fellows and post-doctoral students who work directly with scientists on research projects at AAFC research centres across the country. These individuals work at the research centres via Natural Sciences Engineering Research Council agreements, volunteer agreements or Research Participation Agreements and do not receive a salary or benefits from AAFC. For ease of differentiation between paid AAFC employees, the audit team has defined this group of individuals as non-employees. Given that non-employees are granted access to work in AAFC facilities, they should be provided with OHS training as noted above.

Employee training

• 2.5.6 The audit team selected a sample of employees staffed in positions within AAFC's OHS organizational structure (i.e. Regional Coordinators, Workplace Committee members and employees working for the National Program) as well as a random sample of employees located across the Department. The team reviewed their training records (as of June 23, 2015) to determine whether AAFC OHS mandatory training was taken.
• 2.5.7 As a result of this testing, Internal Audit observed that training had been taken by the Regional Coordinators and employees working for the National Program and a lack of training being taken by key employee groups such as Workplace OHS Committee members and executives within the Department.
• 2.5.8 Training was deemed to have been taken in a timely manner for the sample of employees tested, who had received training, with the exception of the AAFC senior managers tested.

Non-employee training

• 2.5.9 The Canada Labour Code - Part II requirement notes that persons granted access to a facility be familiar with all prescribed safety materials, equipment, devices and clothing.
• 2.5.10 In addition, the AAFC OHS Policy (April 2014) includes roles and responsibilities for AAFC managers which state that the manager is responsible `to ensure that contractors and visitors comply with the Persons Granted Access Directive' and the policy noted that the directive would be developed shortly.
• 2.5.11 The current '5 year Plan' for the National OHS Program scheduled the implementation of the Persons Granted Access directive by June 2015. Internal Audit confirmed with the National OHS Program that the directive is now planned to be developed on a longer term horizon with no specific date established (see recommendation 3 in the monitoring section 2.1).
• 2.5.12 Given the large number of non-employees who access AAFC facilities, Internal Audit selected 6 research centres to determine whether the mandatory OHS training course is provided to non-employees.
• 2.5.13 Interviews with research centre management noted that OHS training is provided when individuals start at the centre and they are not allowed to begin working until they receive their OHS training. However, Internal Audit determined that for 3 out of the 6 centres selected, the AAFC mandatory OHS training was not provided to Natural Sciences and Engineering Research Council students or individuals working in the research centres under Research Participation Agreements. The AAFC research centre managers interviewed advised that they rely on the fact that these individuals received OHS training from either Natural Sciences and Engineering Research Council or the university, therefore the managers deemed the AAFC training to be duplicative. As such, this is non-compliant with AAFC OHS Policy and Canada Labour Code - Part II requirements.
• 2.5.14 The audit team also reviewed the OHS training and awareness programs and supporting tools to determine whether they are established, delivered, monitored and updated to ensure the health and safety of work places.
• 2.5.15 Based on interviews, Internal Audit determined that the national training program was established in 2007 based on training material that was already in place at the Kentville Research Centre. Interviewees at National OHS Program understood that the material was developed based on information and training modules from Employment and Social Development Canada.
• 2.5.16 The training material has not been updated since it was implemented, however, the content was being reviewed by the National OHS Program at the time of the audit.
• 2.5.17 With the exception of training for temporary employees, the Regional OHS Coordinator facilitates the delivery of mandatory training modules in their region at the request of management. Training for temporary employees is provided by management or co-chairs of the workplace committee where the employee is located.
• 2.5.18 Internal Audit observed that the monitoring of training is conducted both at the local and national level. That being said, the Internal Audit team found that the data found in the departmental software and used by the National OHS Program to monitor training is an unreliable source of data as training information is inconsistently being entered into the system.
• 2.5.19 Without consistent delivery of training to all employees and non-employees, there is an increased risk of injury in the workplace.

• 2.5.20 Recommendation

  5. ADM, CMB should ensure that communication is delivered to all AAFC managers on the requirements for providing OHS training to all individuals who are granted access to AAFC facilities.

  Management response:
  Agree

  Action plan:
  The ADM, CMB will target employee categories to communicate the required OHS specific training. This training will specifically target the Executive community, non-employees and all persons granted access for work purposes such as Visiting Fellows, Natural Sciences Engineering Research Council students and volunteers.

  Branch specific training data will be presented as part of the Annual OHS Report (as identified in Recommendation #4) to advise branch heads of their specific rates of training completion.

  The National OHS Program will promote awareness of required training by way of news@work, a targeted training blitz, Executive orientation material as well as the implementation of a National practice for documenting training provided to non-employees.

  Lead(s) responsible:
  Director, Workplace Wellness Programs

  Target date for completion:
  June 2016

Annex A: audit lines of enquiry

Annex B: acronyms

AAFC

Agriculture and Agri-Food Canada

ADM

Assistant Deputy Minister

CMB

Corporate Management Branch

OHS

Occupational Health and Safety

STB

Science and Technology Branch