2020-2021 Audit of Occupational Health and Safety

Executive summary

This audit was included in the Office of Audit and Evaluation’s (OAE) 2019-20 Integrated Audit and Evaluation Plan due to the complexity of Occupational Health and Safety (OHS), and the significant regulatory compliance and reporting requirements that employers must meet.

Agriculture and Agri-Food Canada’s (AAFC) OHS requirements are particularly complex due to the diversity of its workplaces – the Department has employees working in laboratories, farms, and office settings in 55 locations across the country. In 2015, Internal Audit completed an audit of OHS that identified weaknesses in the management control framework for the AAFC National OHS Program and provided five recommendations for improvement.

The objective of this audit was to provide assurance that AAFC has OHS processes and practices in place to support compliance with the Canada Labour Code – Part II – Occupational Health and Safety (Code) and related regulations.

The scope of the audit included key activities that support the Department’s compliance with OHS legal requirements. The audit focused on activities at the workplace and at national level, and included the following areas: AAFC’s OHS management framework, governance and oversight, health and safety training, monitoring and reporting of OHS incidents, and the assessment of the implementation of the Hazard Prevention Program.

Overall, the audit found that AAFC has OHS processes and practices in place to support compliance with the Code and related regulations, but improvements to the National OHS Program are needed to ensure compliance in some areas.

The audit had positive findings for all areas examined related to OHS practices in AAFC workplaces. The audit found that Workplace OHS Committees are established and fulfilling their responsibilities, including monitoring to ensure that employees are provided with the Personal Protective Equipment needed to safely perform their work.

The audit found that job- and location-specific training is tracked and monitored to inform employees against the particular risks such as hazardous substances, animals, or specialized equipment associated with their work. In addition, the audit noted that AAFC has established a process for reporting and monitoring health and safety incidents, which is a requirement of the Code.

The audit found that AAFC has established a National OHS Policy Committee and that the committee is conducting the duties expected. The audit noted that the National OHS Program Office is performing many of its key functions, but noted that improvements are needed in the following areas:

Duties and accountabilities of the Regional OHS Coordinator positions need to be clarified to ensure that they are providing appropriate and consistent OHS services;
National training requirements should be consistently communicated and monitored to ensure completion;
Managers and supervisors should be provided with the training needed to support their OHS responsibilities; and,
A process to conduct regular assessments of the implementation of the Hazard Prevention Program at AAFC workplaces needs to be implemented.

The audit made three recommendations with regard to needed improvements:

Recommendation 1: The Assistant Deputy Minister, Corporate Management Branch, in consultation with the Assistant Deputy Minister, Science and Technology Branch should:
1. clarify the reporting relationship of the Regional OHS Coordinator positions to enable the National OHS Program office to provide the oversight required for the effective delivery of the OHS program; and
2. ensure that roles and responsibilities for the Regional OHS Coordinator positions are documented to clarify expectations and support the consistent implementation of AAFC OHS policies, procedures, and guidelines.
Recommendation 2: The Assistant Deputy Minister, Corporate Management Branch, should implement the following to ensure OHS training is provided to all AAFC employees as required by the Code:
1. develop training for supervisors and managers and ensure all OHS training is delivered in a timely manner;
2. clarify communications regarding the requirements for OHS training for all levels of employees; and
3. clarify and communicate responsibilities for the monitoring of training.
Recommendation 3: The Assistant Deputy Minister, Corporate Management Branch, should implement a process to conduct regular assessment (at least every three years) of the implementation of the Hazard Prevention Program at AAFC workplaces.

1.0 Introduction

1.1 Risk context and objective

Agriculture and Agri-Food Canada’s (AAFC) is spread across Canada at 55 distinct locations, with employees carrying out their duties in four main types of work environments: farms, maintenance facilities, laboratories, and offices. Given the diversity of operations and work environments, AAFC needs to have an Occupational Health and Safety (OHS) framework in place to support the health and safety of employees.

An audit of OHS was included in the 2019-20 OAE Integrated Audit and Evaluation Plan due to the complexity of delivering OHS in AAFC’s diverse workplaces, significant regulatory compliance and reporting requirements, and the findings from the 2015 audit.

The 2015, the Office of Audit and Evaluation internal audit of OHS identified oversight weaknesses in the management control framework for the AAFC National OHS Program and provided five recommendations for improvement. While the management action plans to address the recommendations were completed, a follow-up audit was requested to assess the status of the current OHS framework.

The objective of the 2019-20 audit was to provide assurance that AAFC has OHS processes and practices in place to support compliance with the Canada Labour Code – Part II – Occupational Health and Safety (Code) and related regulations.

Governance and oversight, including whether:
- OHS policies and procedures have been developed and communicated;
- roles, responsibilities, accountabilities, and authorities are clearly defined and communicated;
- the Department has established OHS committees where required, and that they are fulfilling their roles and responsibilities; and
- there is adequate oversight to ensure the Department is fulfilling its OHS responsibilities
Health and safety training, including whether AAFC employees are provided with the OHS training necessary to protect their own health and the health of their employees.
Incident monitoring and reporting, including whether health and safety incidents are investigated, reported, and follow-up occurs.

Audit evidence was gathered through various methods, such as:

observation through site visits to seven of the 20 AAFC research centres;
interviews and a survey of AAFC employees with various OHS responsibilities; and
review of relevant OHS documentation, and analysis of relevant data.

More details about the audit objectives, scope, criteria, and approach are in About the Audit in Annex A.

COVID-19 pandemic

The work related to this audit was near completion when the COVID-19 pandemic occurred, which resulted in a delay in reporting. The scope of the audit was not related to pandemic response activities.

1.2 Overview of occupational health and safety

The Government of Canada protects workplace safety through legislation, programs, and services designed to prevent accidents and injuries on the job. All departments must comply with OHS requirements, including the Code and supporting regulations, and the Treasury Board Policy on Occupational Safety and Health, which define requirements to prevent accidents and injury to health in the workplace.

As stated in its OHS Policy, “AAFC is committed to providing a healthy, safe, respectful, and violence-free work environment for all its employees and persons granted access, by promoting OHS as an integral part of its corporate culture, and integrating OHS into its management and business decision-making processes.” The AAFC’s Hazard Prevention Program is a key component of its OHS policy – it aims to prevent losses, accidents, and injuries in the workplace by addressing hazards at AAFC sites across the country.

Within AAFC, the Corporate Management Branch is accountable for the development and implementation of OHS policies and programs and is responsible for oversight, monitoring, and reporting through the National OHS Program. OHS is a shared responsibility between AAFC and all employees. Key roles within the AAFC OHS structure include the:

National OHS Program Office, responsible for the oversight of AAFC’s OHS program on behalf of the Department;
National OHS Policy Committee, provides an advisory role and participates in the development, implementation, and monitoring of the department’s OHS program;
Regional OHS Coordinators, provide advice and guidance to managers, supervisors, Workplace OHS Committees, and Health and Safety representatives across the country;
Workplace OHS Committees and Health and Safety Representatives, participate in the implementation of national OHS policies and programs, and programs at their workplaces;
Managers and Supervisors, accountable for the implementation of the AAFC OHS policy, and for ensuring the health and safety of employees in their area of responsibility; and
Employees, responsible for their own safety and the safety of those around them, and must report any OHS incidents in the workplace.

2.0 Detailed observations

The following sections present the audit observations organized by the audit’s two primary focus areas – workplace and national OHS activities. Both play important and complementary roles in ensuring the health and safety of Agriculture and Agri-Food Canada’s (AAFC) employees.

Recommendations for improvement are provided after the detailed observations. Management responded to each recommendation and provided the following:

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 Workplace occupational health and safety

Workplace OHS activities are tailored to the type of work done in each location and the related risks. Given that employees work in various settings such as farms, laboratories, and offices, it is important that workplace OHS practices are established and implemented according to the needs of each location.

The audit focused on the following key elements of OHS program requirements for each workplace:

Workplace OHS Committees;
incident reporting and monitoring; and
job- and location-specific workplace safety training.

Overall, the audit found that OHS processes and practices are in place at AAFC workplaces to support compliance with the Canada Labour Code. Workplace OHS Committees are established and fulfilling their responsibilities, including monitoring to ensure that employees are provided with the Personal Protective Equipment needed to safely perform their work.

The audit found that job- and location-specific training is tracked and monitored to inform employees of the particular risks such as hazardous substances, animals, or specialized equipment associated with their work. In addition, the audit noted that AAFC has established a process for reporting and monitoring health and safety incidents as required by the Code, and that it is being conducted at the workplaces assessed during the audit.

The analysis to support these observations are in the following sections.

2.1.1 Workplace OHS committees

The Code requires that workplaces with more than 20 employees establish a Workplace OHS Committee to promote a safe and healthy work environment. Workplace OHS Committees bring together the employer and employees to identify and help resolve OHS issues in the workplace. Health and Safety Representatives must be identified for locations with less than 20 employees.

The Code prescribes the duties of Workplace OHS Committees, which include, but are not limited to:

participating in all inquiries, investigations, studies and inspections pertaining to OHS;
regular monitoring of the effectiveness of OHS programs, and adherence to procedures through regular workplace inspections;
considering and expeditiously handling complaints relating to the health and safety of the employees;
ensuring that adequate records are kept by the employer on work accidents, injuries and health hazards, and regularly monitoring related data; and
participating in the implementation and monitoring of a program for the provision of Personal Protective Equipment, clothing, devices, or materials.

Audit criteria: The audit examined whether Workplace OHS Committees are established, performing the duties required by the Code, and that the roles and responsibilities established in the AAFC OHS Policy and the Terms of Reference for Workplace OHS Committees aligned with the Code.

The audit did not examine whether Health and Safety representatives at workplaces smaller than 20 employees are fulfilling their roles and responsibilities. However, the audit team interviewed Health and Safety representatives to obtain their perspective on the activities included in the audit.

What the audit found: The audit determined that Workplace OHS Committees are established at all AAFC workplaces with more than 20 employees, and that duties set out in AAFC’s OHS Policy and the Terms of Reference for Workplace OHS Committees align with the Code. The audit confirmed that Workplace OHS Committees are performing their required duties, including holding regular meetings to discuss workplace OHS issues, such as incidents, policies, procedures, and local training requirements. The committees monitor to ensure that employees are provided with the Personal Protective Equipment needed to safely perform their work.

The audit found that training is available for Workplace OHS Committee members and Health and Safety Representatives to support them in performing their duties. The AAFC National OHS Program Office has developed a handbook to guide Workplace OHS Committee members, and interviews and survey results confirmed that Workplace OHS Committee members consider their training to be adequate.

An important responsibility of Workplace OHS Committees is to participate in annual workplace inspections, and to discuss the results of inspections and propose actions for improvement with workplace management. For the seven research centres visited during the audit, the audit team observed that annual workplace inspections are being conducted as required, and Workplace Occupation Health and Safety Committees review and discuss the results of inspections and any proposed actions for improvement.

The audit reviewed whether processes are in place to provide employees with Personal Protective Equipment to protect them against injury and illness from workplace risks. The audit found that processes are in place to determine the requirements for Personal Protective Equipment, monitor the provision, use and adequacy of Personal Protective Equipment, and to assess whether improvements are required. Interviews and a survey conducted by the audit team noted that employees have access to, and are using, the prescribed Personal Protective Equipment. The audit found that Workplace OHS Committees review proposed protective measures for new or revised workplace activities.

2.1.2 Incident reporting and monitoring

Reporting and monitoring accidents, occupational incidents and other hazardous occurrences are important components of AAFC’s Hazard Prevention Program, and help to prevent similar incidents from occurring in the future.

Audit criteria: The audit assessed whether a process is in place for recording, reporting, and monitoring accidents, occupational incidents, and other hazardous occurrences, and whether the process is communicated to the members of OHS committees, health and safety representatives, and employees, as required by the Code.

What the audit found: The audit found that AAFC has established a process for incident reporting and monitoring that is communicated to Workplace OHS Committee members and employees.

Information on how to report an incident is accessible and available to all employees on the internal AAFC website, and specialized training courses have been developed by the National OHS Program Office for individuals who are required to investigate and report on incidents. The audit confirmed through interviews and the results of the survey, that there is an awareness of the incident reporting process, and that the process is clear. Survey respondents who had reported an accident or incident, noted that it was properly investigated and follow up was timely.

Review of incident reports for injuries and accidents at the workplaces visited by the audit team found that the incident forms contained all the necessary information, and that the process for the reporting incidents was being completed as defined. The audit found that Workplace OHS Committees review workplace incidents and proposed action plans, and follow-up until corrective action has been implemented.

2.1.3 Job-specific and location-specific training

Training is an important tool to inform employees of their OHS roles and responsibilities, and to educate them on the policies and processes to be followed to support health and safety in the workplace.

Job-specific training is particularly important at AAFC workplaces due to the diverse nature of the work employees perform. While many employees work in office environments, many others work in locations such as farms and laboratories, where they are exposed to different potential hazards. As such, specific training is required to support their safety. Examples include safety training related to operating equipment such as tractors, forklifts and chainsaws, and how to safely handle and transport dangerous products.

Audit criteria: The audit assessed whether training for job- and location-specific workplace safety risks is being tracked, recorded, and monitored. The assessment focused on the seven workplaces visited by the audit team.

What the audit found: The audit found that training for workplace safety is being tracked, recorded, and monitored by local management and the Workplace OHS Committees. Job- and location-specific training is being tracked and recorded through spreadsheets maintained at local worksites, and records are updated and reviewed regularly. The audit confirmed that Workplace OHS Committees are meeting their responsibilities to monitor training completion rates.

Survey responses and interviews with individuals who work with hazardous substances, animals, or specialized equipment, indicated that they are receiving job-specific OHS training before starting any work where these risks are present.

2.2 National Occupational Health and Safety

At the national level, OHS oversight consists of the National OHS Policy Committee and the National OHS Program Office. Both look at OHS from a departmental perspective with the intent of supporting consistency and compliance with the Code and AAFC’s OHS Policy and processes.

The National OHS Policy Committee provides an advisory role and participates in the development, implementation, and monitoring of the departmental OHS program. The National OHS Program Office’s responsibilities include oversight of the OHS program, development of OHS policies, guidance and training, and monitoring the implementation and effectiveness of the AAFC Hazard Prevention Program. Regional OHS Coordinators provide OHS advice and support to workplace management and the Workplace OHS Committees.

This section examined the following elements of OHS at a national level:

National OHS Policy Committee
National OHS Program Office
Regional OHS Coordinators
National OHS Training
Assessment of the Hazard Prevention Program Implementation

Overall, the audit found that AAFC has established a National OHS Policy Committee and that the committee is conducting the duties expected. The audit also noted that the National OHS Program Office is performing many of its key functions, however, the audit noted that improvements are needed in the following areas:

duties and accountabilities of Regional OHS Coordinator need to be clarified to ensure that they are providing appropriate and consistent OHS services;
national training requirements should be consistently communicated and monitored to ensure completion;
managers and supervisors should be provided with the training needed to support their OHS responsibilities; and
a process to conduct regular assessments of the implementation of the Hazard Prevention Program at AAFC workplaces needs to be implemented.

These weaknesses limit the National OHS Program Office’s ability to ensure that the Department is in compliance with the Code and associated regulations and policies.

The analysis to support these observations are in the following sections.

2.2.1 National OHS Policy Committee

All employers with more than 300 employees are required by the Code to establish an OHS Policy Committee at the corporate level. This requirement applies to AAFC as it has approximately 4,700 employees across Canada. The OHS Policy Committee (named the National OHS Policy Committee at AAFC) must carry out the following activities:

inquiries, investigations, studies, and inspections pertaining to OHS (to the extent it considers necessary);
the development and monitoring of a program for the prevention of hazards in the workplace that also provides education for employees in health and safety matters;
the development and monitoring of a program for the provision of Personal Protective Equipment, clothing, devices, or materials;
monitoring data on work accidents, injuries, and health hazards; and
planning for the implementation of changes that might affect OHS, including work processes and procedures.

Audit criteria: The audit examined whether a National OHS Policy Committee is established, and operating in compliance with the duties outlined in the Code, and whether the roles and responsibilities outlined in the AAFC OHS Policy and the committee Terms of Reference align with the Code.

What the audit found: The audit found that a National OHS Policy Committee is established and that the roles and responsibilities defined in the AAFC OHS Policy and the committee Terms of Reference are consistent with the requirements of the Code. The audit found that the committee is carrying out its defined duties, including monitoring OHS incidents, and recommending preventive measures to address any department-wide OHS issues. The committee is participating in planning and developing of OHS programs, such as the Hazard Prevention Program.

2.2.2 National OHS Program Office

The National OHS Program Office is responsible for the oversight of AAFC’s OHS program. Key responsibilities include:

liaising with regulatory bodies, central agencies, and employee representatives; providing advice and guidance to managers and Workplace OHS Committees / Health and Safety Representatives;
coordinating and advising the National OHS Policy Committee;
ensuring a consistent approach to health and safety matters in the department in consultation with National OHS Policy Committee;
developing, communicating, implementing, and monitoring the departmental OHS Program;
coordinating departmental OHS-related education and training programs; and
providing functional direction to Regional OHS Coordinators

Audit criteria: The audit examined whether the National OHS Program Office was fulfilling its responsibilities to provide oversight of AAFC’s OHS program.

What the audit found: The audit found that the National OHS Program Office is fulfilling many of its roles and responsibilities, but weaknesses in several key areas limit its ability to ensure that the Department is meeting its obligations under the Code.

The audit noted the National OHS Program Office is performing many of its important functions, including:

actively supporting the National OHS Policy Committee;
coordinating OHS related-reports such as submissions to central agencies; and
overseeing and contributing to the review and development of OHS policies and programs.

The audit found that a national AAFC OHS Policy (2018) has been defined, is accessible to all employees on the AAFC centralized OHS internal website, and is in compliance with the Code requirement to review and update the policy every three years. In addition, the audit found that AAFC has established OHS training and awareness programs at the national level for employees, executives, members of Workplace OHS Committee, and for those who conduct hazardous occurrence investigations.

However, the audit noted that improvements are needed in several areas to ensure that the Department is meeting the requirements of the Code. The audit found the following:

Regional OHS coordinators did not have a clear understanding of their duties and that the National OHS Program Office lacked the authority to adequately oversee their work;
There is inconsistent communication of training requirements, a lack of adequate training for supervisors and managers, a lack of training completion for executives and Workplace OHS Committee members, and a lack of adequate monitoring being conducted to ensure training is being completed; and
That the National OHS Program Office has not developed a process for monitoring the implementation of the Hazard Prevention Program.

2.2.3 Regional OHS coordinators

Roles and responsibilities of Regional OHS Coordinators

Regional OHS Coordinators provide a key role within AAFC’s OHS Program, acting as liaison between AAFC’s National OHS Program Office and regions, and providing guidance to managers, supervisors, and Workplace OHS committees on compliance with the Code, regulations, Treasury Board, and AAFC OHS policies.

AAFC has nine Regional OHS Coordinator positions located across the country that report functionally to the National OHS Program Office within the Corporate Management Branch. Eight of the nine Regional OHS Coordinators are located in AAFC research centres, providing support to the research centre, and other facilities in their region. These eight Regional OHS Coordinators report administratively to management within the Science and Technology Branch at the research center where the coordinator is located. One Regional OHS Coordinator is located at AAFC’s National Capital Region Headquarters, reporting to the National OHS Program Office within the Corporate Management Branch.

Audit criteria: The audit examined whether the roles and responsibilities for the Regional OHS Coordinator positions are clearly defined, communicated, understood, and consistently applied.

What the audit found: The audit found that the Department has not provided adequate guidance to support Regional OHS Coordinators in fulfilling their responsibilities. AAFC’s OHS Policy and the job description for Regional OHS Coordinators outline their responsibilities in general terms, but they do not include sufficient detail to guide how they should carry out their day to day work.

Regional OHS Coordinators interviewed noted that they have not been provided with clear guidance regarding their roles and responsibilities and that they need additional support and direction. The audit team confirmed that the National OHS Program Office has not developed a manual or handbook to guide the work of Regional OHS Coordinators and to support consistent delivery of OHS services across AAFC (similar to the one developed for the Workplace OHS Committee). The National OHS Program Office noted that while documentation to support the consistency of work conducted by the Regional OHS Coordinators is not in place, coordinators have regular bi-weekly meetings to discuss issues and concerns, and to review program guidance which helps to ensure consistent program delivery.

If Regional OHS Coordinators do not have a clear understanding of their roles and responsibilities, there is a risk that they will not carry out the work required of them, which could result in lack of compliance with the Code, and health and safety issues not being addressed appropriately.

Accountability, authority of the National Program for Regional OHS Coordinators

Audit criteria: The audit examined whether accountabilities and authorities for the Regional OHS Coordinator positions are clearly defined, communicated, understood, and consistently applied.

What the audit found: The audit found that there is a lack of consistency in the accountability and authority of Regional OHS Coordinator positions. Eight of the nine positions report to management in the Science and Technology Branch, which limits the National OHS Program Office in its responsibility to oversee this important function of the OHS program.

Having eight of the nine Regional OHS Coordinator positions report under the Science and Technology Branch limits the ability of the National OHS Program Office to provide oversight, and ensure that OHS services are delivered consistently across the Department. Limitations of the current reporting structures include:

The potential for conflict of interest – management in research centres are the clients of the Regional OHS Coordinator, and also assesses their performance.
Limited direct influence on the work of Regional OHS Coordinators to ensure they are fulfilling their OHS duties. The National OHS Program Office, as well as the other managers within the region that the Regional OHS Coordinators support, are not consulted for input on employee performance. In addition, in the event that there is a need to manage the performance of a Regional OHS Coordinator employee, with the current reporting relationship, it would be difficult to actively monitor and manage their performance as the authority for eight of the positions does not fall under the OHS program.

The potential that local decisions on the management of human resources affect the delivery of the OHS program. In the last six months, two Regional OHS Coordinators received approval from management within the Science and Technology Branch for work assignments outside the department.

Given the small number of Regional OHS Coordinator positions, and the importance of their role to the Department, these gaps could lead to inadequate support being provided to regions on OHS matters, which could pose a significant risk.

Providing the National OHS Program Office with more authority over the Regional OHS Coordinator positions would enable it to provide the oversight required for the effective management of AAFC’s OHS program and it critical functions.

Recommendation 1 – roles and responsibilities, accountability, and authority of Regional OHS Coordinator positions

The Assistant Deputy Minister, Corporate Management Branch, in consultation with the Assistant Deputy Minister, Science and Technology Branch should:

clarify the reporting relationship of Regional OHS Coordinator positions to enable the National OHS Program Office to provide the oversight required for the effective delivery of the OHS program; and
ensure that roles and responsibilities for the Regional OHS Coordinator positions are documented to clarify expectations and support the consistent implementation of AAFC OHS policies, procedures, and guidelines.

Management response and action plan: Recommendation accepted.

Reporting relationship will be changed such that all Regional OHS Coordinator positions will report to the Head of OHS in Corporate Management Branch (National OHS Program Office in Human Resources).
In consultation with regional management from all affected Branches, the Regional OHS Coordinator’s roles and responsibilities will be clarified through the establishment of common performance objectives and service standards to support the consistent implementation and monitoring of AAFC OHS policies, procedures, and guidelines.

Lead(s) responsible

Assistant Deputy Minister, Corporate Management Branch; and
Assistant Deputy Minister, Science and Technology Branch

Director General, Human Resources, Corporate Management Branch

Target date for completion

December 31, 2020
March 31, 2021

2.2.4 National OHS training

Employers are required to ensure employees are provided the information, instruction, training, and supervision necessary to ensure their health and safety at work.

As noted in Section 2.1.3, which discussed job- and location-specific training, OSH training is an important tool to inform employees of the roles and responsibilities and expectations related to OHS. Training is particularly important for managers and supervisors who are responsible to ensure the safety and training of their employees.

The importance of completing OHS training increases the need to have regular monitoring and follow-up processes in place to ensure employees receive information on health and safety risks, responsibilities, and hazard control measures.

Audit criteria: The audit examined whether a training program is in place that includes training for all employee categories, that requirements for training are communicated, that employees received the required training, and that a monitoring process is in place to ensure employees receive the required training.

What the audit found: The audit found that AAFC has established OHS training and awareness programs at the national level for employees, executives, members of Workplace OHS Committee, and for those who conduct hazardous occurrence investigations. All employees have access to high-level OHS orientation that is included in the AAFC’s mandatory Security Awareness online training course.

However, the audit found that there is inconsistent communication of training requirements, a lack of adequate training for supervisors and managers, a lack of training completion for executives and Workplace OHS Committee members, and a lack of adequate monitoring being conducted to ensure training is completed.

National OHS training overview

The National OHS program has a variety of training courses designed to inform employees of their OHS obligations under the Code and to support safe work environments and practices in all AAFC workplaces. Training courses, developed in consultation with the National OHS Policy Committee, include general OHS information as part of employee’s mandatory Security Awareness training, and increases in level of detail and depth based on the roles and responsibilities of the employee.

The training courses at the national level include the following:

Roles and Responsibilities for Employees;
Roles and Responsibilities for Senior Managers (defined as Executives by the National OHS Program); and
Hazardous Occurrence Investigation training.

The delivery of the national level training courses is provided in person by Regional OHS Coordinators in a class-room setting, with the exception of the executive training in the NCR, which is delivered by employees in the National OHS Program Office.

Training courses are a component of AAFC’s OHS Program and are required by the Code to be reviewed and updated as required every three years. The audit observed that the training courses for employees and executives were last updated in 2016 and were therefore due for review in 2019-20. The audit team confirmed through interviews and review of documentation that the training courses are currently in the process of being reviewed and updated.

Communication of training requirements and timelines

Clear communication of mandatory training requirements and the timely completion of training ensures employees are made aware of their health and safety responsibilities.

Requirements for OHS training are communicated to AAFC employees on the training webpage of the AAFC internal website, and on the OHS Program webpage. The AAFC training webpage is the main point of reference for managers and employees in the department with regards to mandatory training. Review of these two webpages noted inconsistencies in the communication of training requirements (Table 1).

**Table 1: National OHS training requirements are not communicated consistently**
Training course	Requirement for completion AAFC webpage	Requirement for completion OHS webpage	Time frame for completion
OHS Roles and Responsibilities for Employees	Not specified as mandatory prior to July 2020.	Mandatory	Not specified prior to July 2020 when it was updated to be completed within 10 days of starting employment with AAFC
OHS Roles and Responsibilities for Senior Managers (for executives)	Mandatory	Mandatory	One year
Source: Adapted form information found on the AAFC Training webpage and the OHS webpage, June 23, 2020

During the conduct of the audit, as a result of the communication of preliminary observations to the National OHS Program Office, the AAFC training website has been updated to include the mandatory requirement for employees to take the CSPS Canada Labour Code online OHS training within 10 days of starting to work for AAFC.

The audit noted that the newly updated requirement for employee training to be completed within 10 days of being appointed to a position at AAFC reinforced the importance of OHS training for employees, however the requirement for executives to complete mandatory OHS training within one year, could be shortened given the importance taking OHS training in a timely manner.

Manager and supervisor training

Employers must provide employees who have supervisory or managerial responsibilities with adequate health and safety training and inform them of their responsibilities under the Code. The audit found that AAFC did not provide adequate information and training to support supervisors and managers in fulfilling their OHS responsibilities.

While all non-executive employees are expected to complete the training established for employees when starting to work at AAFC, this training does not provide specific information for supervisors and managers on their OHS roles and responsibilities.

Although the National OHS Program Office has developed a course called “Responsibilities for Senior Managers”, this training is only for executives. There is no training for managers and supervisors who are not executives to ensure they understand their responsibilities for protecting the health and safety of employees. The National OHS Program Office advised that they are aware of this gap and will develop training for managers and supervisors.

Because it does not offer training specific to supervisors and managers, AAFC is not fully compliant with training requirements outlined in the Code. As well, managers and supervisors may be unaware of their accountabilities and requirements for ensuring the health and safety of all employees in their area of responsibility.

Training completion

The 2015 audit found a lack of training being completed by key employee groups such as executives and Workplace OHS Committee members. To determine whether training is being completed by these employee groups, the audit team reviewed the training records for these groups from January 2017 to December 2019.

Mandatory OHS training for executives is to be completed within the first year of being appointed to an executive position in the Department. The course is designed to inform and remind executive employees of their OHS obligations under the Code. For the period under review, 90% of newly appointed executives were located at AAFC’s headquarters in the National Capital Region.

Review of training records for executives in the National Capital Region noted that the training was last provided in March, 2018 resulting in 14 executives appointed since that date, not receiving the mandatory OHS training. Outside of the National Capital Region, all but one executive employee received the mandatory executive OHS training.

To determine whether members of Workplace OHS Committee completed their mandatory training, the audit team reviewed PeopleSoft training data for the committee members located at the seven locations visited as a part of the audit. The audit found that 50% of Workplace OHS Committee members have not taken the Hazardous Occurrence Investigation training, and 37% have not taken the Workplace OHS Committee Member training.

The National OHS Program Office has switched the employee classroom training to an online course, with employees now required to take online training developed by the Canada School of Public Service. The National OHS Program Office noted that this training is the equivalent to the AAFC OHS Roles and Responsibilities for Employees training that was delivered in person by Regional OHS Coordinators. This change is expected to enable Regional OHS Coordinators to focus on delivering training to other categories of employees, such as managers, supervisors, and executives.

Without consistent delivery of training to all employees, there is an increased risk of a lack of awareness of roles and responsibilities and potential for injury in the workplace.

Monitoring mandatory training

OHS training is a component of the Hazard Prevention Program. The AAFC OHS Policy requires the National OHS Program Office and the National OHS Policy Committee to monitor the implementation of the Hazard Prevention Program to support compliance with the Code, including the completion of OHS training. The audit found that training is being tracked, but monitoring could be improved.

In January 2019, as a result of the inconsistent recording of completed OHS training, the National OHS Program Office established a process to track national training recorded in PeopleSoft. The National OHS Program Office advised that the training information from PeopleSoft is provided to the Regional OHS Coordinators on a quarterly basis for follow-up with employees and management in their respective regions. Regional OHS Coordinators stated that PeopleSoft reports were provided to them in March and June 2019, but not subsequently.

The audit team reviewed the training reports provided to the Regional OHS Coordinators and noted the reports included information on the completion rates for employee and executive training courses. The reports did not include information on other mandatory OHS training, such as training for Workplace OHS Committee members and those who conduct hazardous occurrence investigations.

In reviewing the records of decision for the National OHS Policy Committee, the audit found that national training courses are discussed annually at a high level. However, the audit team found no evidence that the National OHS Policy Committee was provided with information on training completion rates, nor that it was discussed at committee meetings.

Informing employees of their roles and responsibilities under the Code is a necessary component of supporting the health and safety of employees and meeting the employer requirements of the Code. Given the lack of training courses available for all employee categories, inconsistencies in the communication of training requirements, the lack of training completion for executives and Workplace OHS Committee members, and the lack of a process to adequately monitor mandatory OHS training, AAFC cannot be assured that employees are taking the training they need to be aware of their roles and responsibilities

Recommendation 2 – training

The Assistant Deputy Minister, Corporate Management Branch, should implement the following to ensure OHS training is provided to all AAFC employees as required by the Code:

develop training for supervisors and managers and ensure all OHS training is delivered in a timely manner;
clarify communications regarding the requirements for OHS training for all levels of employees; and
clarify and communicate responsibilities for the monitoring of training.

Management response and action plan: Recommendation accepted.

The suite of OHS orientation training will be reviewed and updated to ensure that appropriate training is targeted to (a) executives, (b) managers and supervisors, and (c) employees.

Training for Executives and Supervisors/managers will be delivered on a quarterly basis. Training for employees is available at all times via the Canada School of Public Service (Z065)
Required national OHS training will be listed on AAFC’s Intranet and the Knowledge Workspace OHS page. It will also be communicated through the department’s new employee onboarding program and with letters of offer.
A training monitoring plan will be developed to ensure ongoing tracking of completion and quarterly follow-ups with Workplace OHS Committees and delegated managers to promote participation in required training. Training data will be presented annually at the National OHS Policy Committee and communicated to branch heads.

Lead(s) responsible

Director General, Human Resources, Corporate Management Branch

Target date for completion

March 31, 2021
September 30, 2020
March 31, 2021

2.2.5 Assessment of the Hazard Prevention Program implementation

The Hazard Prevention Program aims to prevent losses, accidents, and injuries in the workplace by addressing hazards at AAFC workplaces across the country. The Hazard Prevention Program provides employees with policies, programs, standards, guidelines, tools, employee education, and information to address these hazards.

The Code requires that employers monitor the progress of the implementation of Hazard Prevention Programs, at least every three years. In addition, the AAFC OHS policy includes responsibilities for the National OHS Program Office and the National OHS Policy Committee for monitoring the implementation of the Hazard Prevention Program across AAFC. Given the decentralized nature of operations across AAFC, monitoring the implementation of the Hazard Prevention Program would contribute to ensuring a uniform approach to health and safety matters in the Department.

In 2015, the audit of OHS found that the National OHS Program did not have a process in place to assess the implementation of the Hazard Prevention Program across AAFC. As a result, it was recommended that National OHS Program Office implement a process to conduct regular assessment (at least every three years) of the implementation of the Hazard Prevention Program at AAFC workplaces.

In 2016, the National OHS Program Office developed a self-assessment checklist to be used by the Regional OHS Coordinators to assess the implementation of the Hazard Prevention Program at each AAFC workplace. This work was to be lead by Regional OHS Coordinators in collaboration with local management and Workplace OHS committees. The National OHS Program Office planned to consolidate the results of the assessments and discuss the results with Regional OHS Coordinators and the National OHS Policy Committee.

Audit criteria: The audit examined whether the National OHS Program Office has a process in place to assess the implementation of the Hazard Prevention Program, and that is has implemented the actions it committed to in response to the 2015 audit recommendation.

What the audit found: The audit found that the National OHS Program Office has not developed a process for monitoring the implementation of the Hazardous Prevention Program.

The audit observed that the self-assessment checklists were completed and consolidated in 2017. However, the audit found no evidence that the results were reviewed by the National OHS Program Office or that they were brought to the National OHS Policy Committee for discussion, as required by the Code.

Interviews with the Regional OHS Coordinators noted that there is a lack of consistency in the use of the checklist and that they have not been provided with direction on how to complete it. The audit team reviewed the self-assessment checklist and observed that there is an opportunity to streamline it. The checklist includes 166 questions, which may be contributing to challenges in completing the template and assessing results.

While a checklist has been developed to assess the implementation of the Hazard Prevention Program across AAFC, it is not a complete process without guidance on how to complete it, and mechanisms to analyze the results and take corrective action.

Without an assessment of Hazard Prevention Program implementation, AAFC is unable to fulfill the responsibility to ensure the consistent application of programs across AAFC to support the safety of employees and is not in compliance with the Code.

Recommendation 3 — Assessment of Hazard Prevention Program implementation

The Assistant Deputy Minister, Corporate Management Branch, should implement a process to conduct regular assessment (at least every three years) of the implementation of the Hazard Prevention Program at AAFC workplaces.

Management response and action plan: Recommendation accepted.

The current Assessment of OHS Requirements self-assessment questionnaire and review process will be streamlined and completion will be monitored. Regional OHS Coordinators will review implementation of the Hazard Prevention Program and overall OHS compliance with the Workplace OHS Committee co-chairs (or Health and Safety Officer, applicable), at least once per year. Results will assist in identifying gaps and best practices across AAFC. The results of the assessment will be presented annually in a report to the ADM CMB and to the National OHS Policy Committee.

Lead(s) responsible

Director General, Human Resources, Corporate Management Branch

Target date for completion

First report to ADM CMB and NOHSPC, September 30, 2021

3.0 Conclusion

The audit concluded that AAFC has Occupational Health and Safety processes and practices in place to support compliance with the Canada Labour Code - Part II - Occupational Health and Safety (Code) and related regulations, but improvements to the National OHS Program are needed to ensure compliance in some areas.

The audit found that job- and location-specific training is tracked and monitored to inform employees of the particular risks, such as hazardous substances, animals, or specialized equipment associated with their work. In addition, the audit noted that AAFC has established a process for reporting and monitoring health and safety incidents that is a requirement of the Code.

At the national level, the audit found that AAFC has established a National OHS Policy Committee and that the committee is conducting the duties expected. While the audit found that the National OHS Program Office is performing many of its key functions, it noted that improvements are needed in the following areas:

The duties and accountabilities of Regional OHS Coordinator need to be clarified to ensure that they are providing appropriate and consistent OHS services;
National training requirements should be consistently communicated and monitored to ensure completion;
Managers and supervisors should be provided with the training needed to support their OHS responsibilities; and,
A process to conduct regular assessments of the implementation of the Hazard Prevention Program at AAFC workplaces needs to be developed and implemented.

The audit made three recommendations to address the improvements required.

Due to the weaknesses observed, a follow-up audit will be included as a part of the AAFC Office of Audit and Evaluation plan to assess the implementation of the recommendations.

Annex A: About the audit

Statement of conformance

The audit conforms to the Institute of Internal Auditors' International Professional Practices Framework, as supported by the results of Agriculture and Agri-Food Canada’s (AAFC) 2020 internal audit quality assurance and improvement program. Sufficient and appropriate evidence was gathered in accordance with the Institute of Internal Auditors' International Standards for the Professional Practice of Internal Auditing to provide a reasonable level of assurance over the findings and conclusion in this report. The findings and conclusion expressed in this report are based on conditions as they existed at the time of the audit and apply only to the areas included in the audit scope.

Audit objective

The objective of this audit was to provide assurance that AAFC had occupational health and safety processes and practices in place to support compliance with the Canada Labour Code - Part II - Occupational Health and Safety and related regulations.

Audit scope

During the planning phase, the audit team interviewed key stakeholders, conducted two research centre site visits, and reviewed and analyzed relevant documents and data, including the observations from the Office of Audit and Evaluation’s 2015 Audit of OHS. Based on the information obtained during the planning phase, the audit team completed a risk assessment to determine the areas to be included in the audit scope. The areas identified as being of greatest risk were used to determine the audit objective, scope, and criteria.

The audit examined whether the following areas are in compliance with the Code and related policies and regulations:

Governance and oversight, including whether:
- OHS policies and procedures have been developed and communicated;
- roles, responsibilities, accountabilities, and authorities are clearly defined and communicated;
- the department has established the OHS committees where required and they are fulfilling their roles and responsibilities for OHS; and
- there is adequate oversight to ensure the Department is fulfilling its OHS responsibilities.
Training and communication: Whether training and awareness programs are in place and communicated with all levels of AAFC staff and whether the above components are established in compliance with the Code.
Monitoring and reporting: The investigation of health and safety incidents, reporting, and follow-up.

The audit examined management practices in place up to March 31, 2020 and the documentation review focused on the period of January 1, 2017 to December 31, 2019. This is the period to which the audit conclusion applies. However, to gain a more complete understanding of the subject matter of the audit, we also examined certain matters that preceded and followed these dates.

The audit did not assess programming related to pregnant and nursing employees and violence prevention as the associated regulations and legislations came into force during the conduct of the audit. Due to the due to the complexity of work performed, OHS practices in AAFC’s Level II laboratories were excluded from this audit.

Audit criteria

The following audit criteria were developed to ensure sufficient and appropriate testing to support the audit objective and opinion. Criteria were based on requirements set out in OHS legislation, regulations, and AAFC policy.

Criterion 1: The Department has formally defined and communicated policies in relation to Occupational Health and Safety that are in compliance with legal requirements
Criterion 2: Occupational Health and Safety Governance Committees and Safety Representatives are established and operate in compliance with legal requirements
Criterion 3: Training and awareness programs are in place, communicated with all levels of AAFC staff, and comply with legislative requirements
Criterion 4: OHS roles, responsibilities, accountabilities, and authorities are clearly defined, communicated, assumed, understood, and consistently applied
Criterion 5: A prescribed program for incident monitoring and reporting is in place and in compliance with legal requirements

Audit approach

The audit approach and methodology were risk-based and consistent with the “International Standards for the Professional Practice of Internal Audit” and the Treasury Board “Policy on Internal Audit”. These standards require that the audit be planned and performed so as to conclude against the objective. The audit was conducted in accordance with an audit program that defined audit tasks to be performed in the assessment of each audit criterion.

For each criterion established, an audit methodology was developed to ensure that sufficient and appropriate audit evidence is collected to enable the audit team to conclude on the audit objective.

To complete the engagement, the following methods were used:

observation through site visits of eight research facilities;
survey of 120 AAFC employees working within the Science and Technology Branch, located at research centres and farms across Canada. There were 29 respondents;
review of key OHS documentation that included, among other documents, the following:
- Records of Decisions from for 11 Workplace OHS Committees and the National OHS Policy Committee;
- sample of 19 Lab 1070s Hazardous Occurrence Investigation Reports;
- Workplace Inspection Reports completed from five locations; and,
- sample of 24 completed Job Safety Analysis documents.
interviews with 40 key stakeholders including:
- National OHS Policy Committee - employer and employee representatives;
- Workplace OHS Committees - employer and employee representatives;
- National OHS Program;
- Regional OHS Coordinators;
- Health and Safety Representatives;
- Health and Safety Coordinators;
- Associate Directors, Research Development and Technology; and
- Managers/Supervisors located at research facilities visited.