ARCHIVED - Audit of Occupational Health and Safety - Audit Report

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Table of Contents

1.0 Executive Summary

The Canadian Food Inspection Agency (CFIA or the Agency) is committed to providing a safe and healthy working environment for all its employees, promoting occupational health and safety (OHS) as an integral part of its corporate culture, and integrating OHS into its management and business decision making processes. The CFIA acknowledges that OHS is a top priority and that CFIA workplaces bear an inherent level of risk. CFIA employees carry out their work duties in three main types of work environments: offices, laboratories, and other work environments, such as slaughterhouse and other third party establishments, which are highly decentralized and varied. Compared to an office work environment, the lab and other work environments have a higher degree of inherent risk of a work-related injury, accident, illness, or fatality.

The Canada Labour Code - Part II Occupational Health and Safety (CLC Part II) is intended to prevent accidents and injury to health in the course of employment. The CLC Part II, its related regulations, and the provisions of the collective agreements between CFIA and its employees, form the basis for the Agency's OHS mandate. In cases where the CFIA does not control the physical working environment, such as third party premises, the CLC Part II and its regulations apply to the extent that the CFIA controls the work activity being carried out at such premises.

The Agency's OHS activities are also governed by the National Joint Council OHS Directive, the Employment and Social Development Canada (ESDC) – Labour Program, the Government Employees Compensation Act, and various CFIA policies and directives, as well as the CFIA Laboratory Safety Manual. The CFIA OHS Policy recognizes that OHS is a shared responsibility while assigning specific roles and responsibilities to persons and committees. The Agency's Workforce and Workplace Relations Directorate, Human Resources Branch (HRB), is the functional lead for OHS.

On an annual basis, all federally regulated businesses and industriesFootnote 1, including the CFIA, are required to report to ESDC's Labour Program the total number of disabling and non-disabling (minor) injuries, fatalities and other hazardous occurrences. Over the past seven years, the CFIA has reported a downward trend in the Injury Frequency RateFootnote 2 (IFR). While this rate is not comparable due to the diversity between industrial sectors, the CFIA has experienced an average decline in IFR of 34.5%. During this time period, there were no fatalities at CFIA and minor injuries accounted for the majority of the hazardous occurrences. The improved injury frequency rate supports the Agency's strong commitment to providing a safe and healthy working environment for all its employees.

At the outset of the audit, it was identified that the OHS management control framework is principally decentralized with no complete, formal, and coordinated OHS program. The audit provided an opportunity to examine operational level aspects of the Agency's OHS program.

The objective of the audit was to provide assurance that the Agency has management controls in place in support of compliance with legal requirements of the CLC Part II and related regulations, pertaining to OHS committees and health and safety representatives, training and awareness, hazard prevention, and lab safety. The audit did not constitute a technical review and did not seek to provide assurance on the safety of the workplace or its employees.

We found that the Agency has an overall OHS policy that defines high level roles and responsibilities including those for OHS Committees, health and safety representatives, advisors and coordinators. While a good structure is in place in Areas and laboratory facilities, there is a lack of centralized and coordinated OHS program to ensure effective and consistent implementation and application of federal legislative requirements.

OHS training and awareness programs vary between Areas and do not provide for a consistent minimum base of knowledge and awareness for OHS committees and health and safety representatives, as well as employees carrying out the same inspection duties. OHS training is not always taken and tracking/monitoring does not always occur.

The Agency does not have a fully developed and implemented national hazard prevention program. At the operational level, hazard prevention program activities are largely unstructured and vary between Areas. Hazard identification and assessment is mainly reactionary and preventative measures are discretionary. There is insufficient communication and training to managers and supervisors on the minimum mandatory requirements established for training and use of personal protective equipment, devices and materials for employees in ship and slaughter inspection. OHS impacts and requirements are not taken into consideration when new programs are being developed or existing ones changed.

A formal lab safety program exists and is documented in the Lab Safety Manual. The Agency has also put in place a mechanism for continual performance review of the program. The audit noted some opportunities for improvement including clarifying roles, responsibilities, and accountabilities in support of the lab safety program.

Conclusion

The audit concluded that the Agency management controls are not fully in place to support compliance with legal requirements of the CLC Part II and related regulations. CFIA's OHS framework is expected to improve with the strengthening of a centralized structure and oversight and the implementation of common core requirements that will allow the flexibility to address individual operational Area and Branch needs.

2.0 Introduction

2.1 Background

The Canadian Food Inspection Agency (CFIA or the Agency) is committed to providing a safe and healthy working environment for all its employees, promoting occupational health and safety (OHS) as an integral part of its corporate culture, and integrating OHS into its management and business decision making processes. The CFIA acknowledges that OHS is a top priority and that CFIA workplaces bear an inherent level of risk. CFIA employees carry out their work duties in three main types of work environments: offices, laboratories, and other work environments, such as slaughterhouse and other third party establishments, which are highly decentralized and varied. Compared to an office work environment, the lab and other work environments have a higher degree of inherent risk of a work-related injury, accident, illness, or fatality.

The lab work environment varies in terms of the activities conducted depending upon the nature of the lab, the program it supports, and bio-containment levels. The lab work environment includes potential exposures to, for example, chemicals, pathogens, infectious substances, carcinogens, radiation, sharp tools, combustible and corrosive materials, and live animals.

The "other" category has the highest amount of variability of tasks and decentralization. These work environments include, but are not limited to, ships and transfer vessels, meat slaughterhouses, farms, animal quarantine facilities, retail establishments, storage facilities, canneries, etc. The nature of the work performed by a CFIA employee takes place in facilities or properties owned and operated by third parties and involve tasks which have a high inherent risk of injury (e.g. working with sharp tools, slippery floors, noise, chemical exposure, repetitive physical movement, live animals, moving machinery, etc.)

The Canada Labour Code - Part II Occupational Health and Safety (CLC Part II) is intended to prevent accidents and injury to health in the course of employment. The CLC Part II, its related regulations, and the provisions of the collective agreements between CFIA and its employees, form the basis for the Agency's OHS mandate. In cases where the CFIA does not control the physical working environment, such as third party premises, the CLC Part II and its regulations apply to the extent that the CFIA controls the work activity being carried out at such premises.

The Agency's OHS activities are also governed by the National Joint Council OHS Directive, the Employment and Social Skills Development Canada – Labour Program, the Government Employees Compensation Act, and various CFIA policies and directives, as well as the CFIA Laboratory Safety Manual. The CLC Part II requirements are broad and varied, including but are not limited to, the following: Hazard Prevention; Training and Awareness; Incident Reporting; Protective materials, equipment, devices, clothing; OHS Committees and Representatives; Employer responsibilities with respect to OHS (including duties to OHS Committees and Representatives); Facilities; First Aid; Vehicles; Emergency Preparedness; and Violence in the Workplace. The CFIA reported an Injury Frequency Rate (IFR) that has decreased from 14.2 in 2007 to 9.3 in 2013. During this time period, there were no fatalities at CFIA and minor injuries accounted for the majority of the hazardous occurrences.

The CFIA OHS Policy recognizes that OHS is a shared responsibility while assigning specific roles and responsibilities to persons and committees. The Agency's Workforce and Workplace Relations Directorate, Human Resources Branch (HRB), is the functional lead for OHS. The CFIA's senior management, managers and supervisors have specific OHS responsibilities which they are expected to carry out directly to help ensure the safety of staff, visitors and contractors in their area of responsibility. They are supported by the OHS committees and OHS advisors and coordinators, who also have monitoring and oversight responsibilities in addition to their support role. Employees are expected to follow the OHS procedures established for the workplace and to take precautions that help ensure their own health and safety, as well as that of fellow employees.

At the time of the audit, the CFIA's OHS structure was as follows:

Click on image for larger view
Flowchart - Canadian Food Inspection Agency's Occupational Health and Safety structure. Description follows.

Description for the CFIA's OHS structure
  • The CFIA OHS organizational chart illustrates the responsibilities for OHS between CFIA Branches and within each one. The chart also illustrates the linkeage of OHS responsibilities within each branch to the various OHS committees.
  • There are four dark blue rectangle boxes horizontally across the top of the org chart to illustrate the four CFIA Branches with OHS responsibilities. They are: 1) Human Resources Branch, 2) Science Branch, 3) Corporate Management Branch and 4) Operations Branch.
  • Below each Branch box, there are vertical light grey boxes to illustrate further areas of OHS responsibility within each branch. They are as follows:
    • Below the HR Branch box, there are two vertical light grey boxes: Workforce and Workplace Relations Directorate and Corporate OHS. Below the Corporate OHS box, there are two parallel organization chart boxes: one for Area OHS Advisors and one for the National Lab Health and Safety Coordinator.
    • Under the Science Branch box, there are two vertical light grey boxes: CFIA Laboratories and Lab Health & Safety Coordinators (12). There is a dashed line from the Lab Health & Safety Coordinators box to the National Lab Health & Safety Coordinators box under the Human Resources Branch to illustrate their relationship.
    • Under the Corporate Management box, there are two vertical light grey boxes: Assets & Security Management Directorate and Real Property & Environmental Management Directorate. There is a dashed line from the Real Property & Environmental Management Directorate to the CFIA Laboratories box under the Science Branch to illustrate their relationship.
    • Under the Operations Branch box, there are two vertical light grey boxes: Area Operations (Management Services Directorate) and Area OHS Advisors (4). There is a dashed line from the Area OHS Advisors box to the Corporate OHS box under the Human Resources Branch to illustrate their relationship. There is also a dashed line from the Area OHS Advisors to the following four green oblong shaped boxes at the bottom of the chart: Area OHS Policy Committee (4), Regional OHS Policy Committee (17), Work Place H&S Committee and Health and Safety Representatives. There are dashed lines connecting these committees to the Area OHS Advisors box under the Operations Branch. The Work Place H&S Committee box is also connected to the Area OHS Advisors box with a dashed line.
  • In addition to the above mentioned four green oblong boxes at the bottom of the chart, there is a fifth box to illustrate the National OHS Policy Committee. There is a dashed line from this policy committee's box to the Corporate OHS box under the Human Resources Branch to illustrate their relationship.
  • Below the organizational structure boxes, there are four paragraphs of text that describes each of the OHS committees listed in the oblong green boxes. The text paragraphs are as follows:
    • National OHS Policy Committee – Legally required, as per CLC II (134.1), for employers who normally directly employ 300 or more employees must establish a policy health and safety committee. Its purpose is to develop, implement, and monitor Agency OHS policy and OHS program initiatives and to make recommendations to the President on OHS matters affecting employees.
    • Area & Regional OHS Policy Committees – Established by the Agency, under CLC II (134.1), a forum where management and employee representatives meet to exchange information, discuss policies, programs and conditions as they pertain to Occupational Health and Safety in their area or region.
    • Work Place Health and Safety Committees – Legally required, as per CLC II (135.1), to be established in work places where there are 20 or more employees for the purpose of addressing health and safety matters that apply to individual work places.
    • Health and Safety Representatives – Legally required, as per CLC II (136.1), and must be appointed for each work place with fewer than 20 employees. They are responsible for addressing work place health and safety issues.

* The number of Work Place H&S Committees and H&S Representatives could not be clearly determined in all CFIA Areas.

The Agency is in the process of centralizing OHS services through the use of service level agreements with Corporate Management, Science, and Operations Branches.

At the outset of the audit, it was identified that the OHS management control framework is principally decentralized with no complete, formal, and coordinated OHS program. The audit provided an opportunity to examine operational level aspects of the Agency's OHS program.

The audit of OHS was identified and approved in the Agency's 2012/13 to 2014/15 Risk Based Audit Plan and supported by the Human Resources Branch to inform its planning and implementation of a National OHS Program.

2.2 Objective

The objective of the audit was to provide assurance that the Agency has management controls in place in support of compliance with legal requirements of the CLC Part II and related regulations, pertaining to OHS committees and health and safety representatives, training and awareness, hazard prevention, and lab safety.

2.3 Scope

The scope of the audit focused on control activities in support of compliance and did not constitute a technical review of OHS.

The following control activities were examined as part of the audit: (1) OHS Committees and Health and Safety Representatives, (2) Training and Awareness, (3) Hazard Prevention, and (4) Laboratory Safety.

The period of activity covered by the audit was April 2011 to December 2013 for activities in the Human Resources, Operations, and Science Branches.

The audit commenced February 2013 and the field work was completed in December 2013.

2.4 Approach and Methodology

Detailed audit criteria (see Appendix A) were developed to serve as standards against which our assessment could be made, and form a basis for the conduct of the audit. A risk assessment was conducted in order to identify the audit objective, scope and criteria for the two key risk statements identified for OHS:

  • The Agency's staff are not carrying out their work safely
  • The Agency is not meeting its OHS legal requirements

The risk assessment identified the key legal requirements that most affect OHS operational effectiveness: (1) OHS Committees and Health and Safety Representatives, (2) Training and Awareness, (3) Hazard Prevention, and (4) Laboratory Safety. The risk assessment also identified the laboratory, slaughterhouse, and marine vessel work environments as having a higher risk of injury, accident, illness or death than others encountered by Agency staff.

The audit criteria were developed from the key controls set out in the CLC Part II and related regulations, and the Treasury Board Secretariat's Audit Criteria related to the Management Accountability Framework: A Tool for Internal Auditors.

Audit methodology included documentation review, interviews and surveys, site visits including point-in-time observations, and consultation with subject-matter-experts.

2.5 Statement of Conformance

The audit conforms to the Internal Auditing Standards for the Government of Canada, as supported by the results of the CFIA's internal audit quality assurance and improvement program. Sufficient and appropriate auditing procedures were performed and evidence gathered in accordance with the Institute of Internal Auditor's International Standards for the Professional Practice of Internal Auditing and to provide a high level of assurance over the findings and conclusion in this report. The findings and conclusions expressed in this report are based on conditions as they existed at the time of the audit, and apply only to the entity examined.

3.0 Findings and Recommendations

3.1 OHS Committees and Health and Safety Representatives

While OHS committees and health and safety representative structures are in place, insufficient functional direction and monitoring has contributed to not operating in full compliance with CLC Part II.

Existence of OHS Committees and Health and Safety Representatives

We expected that a health and safety policy committee, work place health and safety committees, and health and safety representatives exist according to CLC Part II requirements. We also expected committees to have addressed certain requirements under the CLC Part II, such as rules of procedure, member selection, terms of office, and meeting frequency.

The Agency has a health and safety policy committee, the National OHS Policy Committee (NOHS PC), as required by the CLC Part II. In addition, the Agency has established policy committees in the Areas and Regions as a forum where management and employee representatives meet to exchange information, discuss policies, programs and conditions as they pertain to occupational health and safety in their area or region.

The NOHS PC has an approved Terms of Reference (ToR) that establishes its rules of procedures. We found that six members had exceeded the two year maximum term of office as required by the CLC Part II. While there is provision in the CLC Part II to reappoint members, no formal record confirming reappointments was found. In addition, the ToR was not being adhered to as all members and alternates did not meet the executive level criteria. While the ToR was updated every two years, it had not been approved.

Although the Agency has work place health and safety committees and health and safety representatives in place, we could not determine if they were established in compliance with the CLC Part II. We found that there was no CFIA national direction or guidance to support meeting this legal requirement. We noted variation between Areas on the approach or methodology used to determine where work place committees and representatives should exist. All Work Place Health and Safety Committees sampled had a ToR but they did not always indicate terms of office.

Generally, the NOHS PC and Area, Regional and Work Place Health and Safety committees met at their required frequency and maintained records of meetings.

Effectiveness of OHS Committees and Health and Safety Representatives

The OHS and Prevention Division, Workforce and Workplace Relations Directorate, HRB, as the Agency's OHS functional lead (Corporate OHS), is expected to manage and coordinate the implementation of the Agency's health and safety program as per their roles and responsibilities outlined in the 2012 CFIA OHS Policy. In 2011, an independent study of the CFIA OHS Program identified a number of weaknesses including the lack of a strong Corporate OHS function and no complete, formal and coordinated OHS Program.

The audit confirmed that Corporate OHS is not fulfilling all of its roles and responsibilities in supporting the Agency to comply with CLC Part II, such as providing clear and timely direction on health and safety matters to OHS Advisors and the National Lab Health & Safety Coordinator, coordinating CFIA wide educational material and training programs and promotional campaigns; monitoring the CFIA National OHS Program; maintaining a national database on accident investigations; maintaining statistical reports, minutes of health and safety committees and reports for the purpose of reporting trend analysis to senior management.

We reviewed the NOHS PC records from 2011 to 2013 to determine whether legally required committee duties were being addressed. We found that the NOHS PC was participating in some required activities, such as the development of OHS policies and programs and addressing issues raised, but not others, such as:

  • The development and monitoring of OHS programs such as hazard prevention, employee education, and personal protective clothing and equipment;
  • Monitoring data on work accidents, injuries and health hazards; and,
  • Participating in the planning of the implementation of changes that might affect health and safety, including work processes and procedures.

We also reviewed the Area and Regional, and Work Place Health and Safety Committee records to review operational level OHS committee activities and to determine whether legally required committee duties were being addressed. In the records reviewed, we found that these committees were addressing many of their legally required duties to varying degrees. The records indicated that little or none of the following duties were addressed:

  • Participation in the planning and / or implementation of changes that might affect OHS, including work processes and procedures;
  • Participation in the development or implementation of a program, and the monitoring of said program, for the prevention of hazards in the work place that also provides for the education of employees in health and safety matters.

Most health and safety representatives reported that they have access to information and resources to function effectively and network with their local OHS committee more than five times per year. While health and safety representatives reported they are carrying out many of their legally required duties, they identified that they are not addressing some duties, such as:

  • Participating in the monitoring of a hazard prevention program and a personal protective equipment, materials and devices program, and,
  • Participating in the implementation of changes that might affect OHS, including work processes and procedures.

Recommendation 1

The VP Human Resources Branch should ensure that Corporate OHS fulfills its roles and responsibilities as functional lead for OHS, in support of compliance with legal and other requirements, including

  1. the development and implementation of a standard methodology to determine where there should be a work place health and safety committee or health and safety representative;
  2. ensuring committees and health and safety representatives are performing their legally required duties; and,
  3. coordinating, monitoring and reporting on the National OHS Program.

3.2 Training and Awareness

OHS training programs need to be strengthened to meet the needs and requirements of OHS committee members, health and safety representatives and Agency employees. Training is not consistently tracked and monitored across the Agency.

The CLC Part II requires the Agency to provide training to members of committees, health and safety representatives and employees, including those with supervisory or managerial responsibilities.

There is no national standardized CFIA OHS orientation program in which OHS committee members, health and safety representatives and Agency employees can participate. While we found that an OHS orientation course and / or introductory material are available in most Areas, the content and whether the course is mandatory varies between Areas, and course completion is not always recorded and tracked (e.g. in PeopleSoft).

We expected that OHS training is provided and include the activities in which the health and safety committees and representatives are involved as per the CLC Part II, as well as the topics outlined in the CFIA OHS Training Directive. We also expected activities to be in place to track and monitor training.

Training material exists for NOHS PC; however, delivery of training to NOHS PC members is currently not occurring and their training is not being tracked. In addition, training of committee members and health and safety representatives by Area OHS Advisors is occurring; however, the materials and tracking of training vary between Areas. We found that training materials do not always clearly address required activities related to committee and health and safety representatives' roles and responsibilities as per CLC Part II and Canada OHS Regulations (COHSR), as well as topics in the CFIA OHS Training Directive.

As part of the audit, we examined training and awareness for ship and slaughterhouse inspection supervisors and inspectors. We expected training and awareness to be in place for these inspection supervisors and inspectors, and that their OHS training needs be tracked and monitored.

In some Areas, the materials used to train committees and health and safety representatives are used to train inspection supervisors. As noted above, the content of this training material varies between Areas and does not always clearly address required activities related to roles and responsibilities as per CLC Part II and COHSR, as well as topics in the CFIA OHS Training Directive.

There is no national standardized education program in place at CFIA specifically for ship or slaughterhouse inspection staff that identifies their expected mandatory minimum OHS training. This area is further examined as part of Section 3.3.

Recommendation 2

The VP Human Resources Branch should ensure that the training materials developed for OHS committees and Health and Safety representatives provide for a consistent base of knowledge and awareness in support of effectively carrying out their roles and responsibilities under CLC Part II and topics identified by the Agency.

Recommendation 3

The VP Human Resources Branch should develop and implement a common approach to the identification of training needed and tracking of training taken by OHS committee members, health and safety representatives and Agency employees to ensure they receive training in health and safety as required by CLC Part II.

3.3 Hazard Identification and Prevention for Employees in High Risk Work Environments (Ship and Slaughter)

The Agency's national hazard prevention program is not fully developed and implemented. At the operational level, hazard identification and assessment is mainly reactionary and preventative measures are discretionary, and minimum mandatory preventive and protective measures do not exist for employees working in high risk environments.

The CLC Part II requires there to be a hazard prevention program (HPP) in place. A HPP is a workplace specific program designed to prevent accidents and injuries in the workplaces, through proactive hazard identification, assessment, control, and employee education.

We expected the HPP would include the following legally required components: implementation plan, hazard identification and assessment methodology, an identification and assessment of hazards in the work place, preventative measures to address assessed hazards, employee education, and an evaluation of the HPP.

The Agency does not yet have a fully developed and implemented national HPP, but does have a draft document (Corporate HPP Standard, August 2013), that identifies all legally required components of an HPP. This document is incomplete and is not in sufficient detail to support the design of a HPP. For example, it does not provide information on how to identify those who need training on assessing ergonomic hazards, how monitoring of implementation of the HPP will occur, the timeframe for reviewing and revising the hazard identification and assessment methodology, record keeping requirements, and how to educate employees on changing and emerging hazards. As well, program evaluation activities to be carried out by Corporate OHS, in consultation with NOHS PC, are not clearly addressed. There is no articulation of what, when, or to whom information is to be provided by managers responsible for evaluating the effectiveness of their site's HPP.

As a consequence, there is an increased risk that those with HPP responsibilities will not be able to effectively carry out related activities and achieve the intended results of the Agency's HPP.

Recommendation 4

The VP Human Resources Branch should ensure that the Agency's HPP is in place and in sufficient detail to fully support meeting legal requirements. This should include expected methodology and processes for hazard identification and assessment.

Recommendation 5

The VP Human Resources Branch should clearly communicate national expectations for the implementation of hazard identification and prevention, monitor each Area's implementation of the HPP and report on the status of its implementation to Agency governance and NOHS PC.

As part of a HPP, we expected for employees carrying out their duties in high risk work environments, that the associated hazards be identified and assessed, training and awareness activities occur, and that employees apply preventative measures such as the use of personal protective equipment, devices and materials (PPE) and reporting of hazardous occurrences.

In ship and slaughterhouse work environments, employees carry out their work in a safe manner based on formal and informal identification of hazards and related preventative measures.

There is no national repository of identified and assessed hazards for the CFIA's work environments. At the operational level, hazard identification and assessment and related preventative measures are sometimes documented on a Job Hazard Analysis (JHA) form. When JHAs are used, they do not always clearly demonstrate inclusion of key legal requirements such as the frequency and duration of exposure to the hazard or its effects and prioritization of preventative measures. As well, linkage to expected training and the identification of whether PPE usage is mandatory varies between JHAs. This may suggest that hazard identification and assessment methodology, and its application, may not be fully understood which could lead to employees being at an increased risk of injury, accident, or illness.

We found that hazard identification and assessment in ship and slaughterhouse work environments is mainly reactionary and based on issues raised by inspectors and supervisors, such as those arising from observations and incidents occurring in their work environment, work place inspections, and information from third party operators. Carrying out work in a safe manner is based on individual judgment and reliance on experience of colleagues and third party operators.

Ship and slaughterhouse inspection staff receive on-the-job training as a preventative measure. Employees' awareness of OHS in high risk work environments occurs in a variety of ways, such as, day-to-day discussions amongst inspection staff, staff meetings, sharing of OHS committee minutes, distribution of memos and materials provided by Area OHS Advisors.

While employees benefit from on-the-job training, any formal training mostly occurs after carrying out inspection duties for the first time. Factors contributing to this timing include operational pressures, shift rotation, staff shortages, lack of connectivity, availability of computers, and geographic dispersion. As well, while the Agency's national Pre-Requisite Employment Program and Meat School inspection training contains an OHS component, this training is not mandatory for all inspectors.

OHS materials by topics specific to ship inspection and slaughterhouse work environments exist and they are provided to employees based on needs and issues that arise in each Area. We also found that OHS training made available to and taken by employees varies amongst employees working in the same high risk work environment. Training needed was not always documented and monitoring of training taken varied in its formality between and within Areas. As a consequence of the current approach to training, employees exposed to the same hazards, even at varying frequencies, may not have a sufficient awareness and knowledge base from which to make decisions to help reduce the likelihood or severity of an injury.

CFIA has not established standard minimum mandatory requirement for use of PPE in high risk work environments. As such, PPE usage by employees is based on their judgment and by the expectations of the third party operator (ship or slaughterhouse). We observed PPE usage varies between Atlantic and West Area ship inspectors for the same activities being performed. Overall, the usage of PPE and the circumstances in which it is expected to be used is left to the discretion of the individual.

Interviewees in both ship and slaughter identified that accidents and injuries, including near misses, are not always formally documented and reported, and their most commonly identified training gap was hazardous occurrence and incident reporting (HOIR). When reported, the type of hazardous occurrence and injury was not always provided or could not be determined. Information from HOIRs, including near misses, is an indicator of the effectiveness of hazard prevention activities, and may signal new or emerging hazards, a need for new or additional safe work practices, awareness of need to use PPE, etc. As well, employees have a legal duty to report and OHS committees have a legal duty to monitor this data.

Overall, inspectors and supervisors in ship inspection and slaughter articulated their awareness of hazards in their work place and were able to identify the types of things they consider or do in order to help ensure their own health and safety. Slaughterhouse inspectors reported that continuous and repetitious exposure to hazards built experience in carrying out duties in a safe manner, yet also created a de-sensitivity to and a reduced awareness of the hazards in the work environment. Ship inspectors are aware of their right to refuse dangerous work and feel supported; however, the potential financial impact to regulated parties, operational pressures, potentially negative perceptions by peers, and employment status, are factors they consider when deciding whether to board a ship at sea even if they are "uncomfortable".

We found that there no formal process in place to ensure OHS impacts and requirements are taken into consideration when new policies or programs are being developed or existing ones changed. For example, in fiscal 2011/12, the frequency of ship inspection for Asian Gypsy Moth increased, and activities to address employees' health and safety were not considered until after incidents occurred, including injuries. The Agency subsequently recognized that the increased requirement for ship inspections at sea, combined with the especially hazardous conditions in the Atlantic Ocean, posed a significant danger to ship inspectors, especially during the boarding of ships for inspection. As a result, ship boarding and transferring at sea risk assessment was performed and preventative measures were put in place to reduce the risk of future hazardous occurrences.

Recommendation 6

The VP Human Resources Branch should ensure, based on the nature of the work place and the hazards associated with it, that minimum mandatory training and PPE requirements be developed, implemented and monitored for high risk work environments identified by the Agency.

Recommendation 7

The VP Human Resources Branch should reinforce employees' responsibility for formally recording and reporting hazardous occurrences including near misses to support compliance with CLC Part II.

Recommendation 8

The VP Human Resources Branch, in consultation with Policy and Programs Branch and Operations Branch, should develop and implement processes to ensure OHS impacts and requirements are taken into consideration when new programs are being developed or existing ones changed.

3.4 Laboratory Safety

A formal lab safety program exists and is documented in the Lab Safety Manual. A mechanism also exists for continual performance review of the program. Roles, responsibilities, and accountabilities in support of the lab safety program were not always clear.

We expected there to be a prescribed program for lab safety in support of compliance with the CLC Part II and related COHSR. We also expected there to be an assessment of the lab safety program and an evaluation of its results.

CFIA Lab Safety Manual

The Agency's Lab Safety Manual (LSM), including related supporting materials, is intended to articulate the lab safety program. The LSM includes information related to the CLC Part II and COHSR, as well as other governing requirements and recommended practices, such as biosafety standards and guidelines. Three editions of the LSM have been issued since 2002, with the most recent 3rd edition issued in April 2012.

Although not formally approved by Science Branch senior management, use of the LSM and related Continual Performance Review (CPR) activities was found to be generally accepted by CFIA lab staff. In general, the content of the LSM was found to be sufficient in relation to the CLC Part II and COHSR. Certain provisions related to facilities management and administrative record keeping were not covered. We also found opportunities to further strengthen the effectiveness of the LSM, such as clarification of what is mandatory versus good practice, roles and responsibilities, and alignment with the CPR booklet.

Continual Performance Review

The CPR is the mechanism used to evaluate the lab safety program, and when carried out, it is done against the content of the LSM. As such, the Agency is inherently assessing its compliance with the CLC Part II and COHSR.

We found that CPR requirements were missing information from the LSM and contained information that was not in the LSM. As well, verification activities in the CPR were not always appropriately or sufficiently designed to support the objective of the CPR.

Three CPR have been conducted to-date. The first two were carried out by the National Lab Health & Safety Coordinator (NLHSC), a position independent of the labs. The most recent CPR was decentralized to the labs through the use of a CPR self-assessment.

Under the decentralized regime, no training was provided on how to carry out a CPR, judgment was applied by those who participated, and a need for more knowledge and direction was expressed. There was variation in how the CPR were carried out, such as differences in interpretation, completeness of verification activities, documentation of results, and related action plans.

In response to the CPR, each lab developed its own action plans and all lab health and safety committees' objectives were created, based on their individual lab results. The NLHSC and the Lab Health & Safety Coordinators then developed a national action plan for lab safety that was shared with the Lab Directors.

Roles, Responsibilities, and Accountabilities for Lab Safety

We found that roles, responsibilities, authority, oversight, and direction for the lab safety program were not always clear. Inconsistent information exists, for example, in the LSM, CFIA's OHS Policy, and the service level agreement between Science Branch and HR Branch. As well, OHS services provided to labs by other branches or where CFIA staff is co-located with other government departments is not always fully defined, formalized and monitored. Science Branch and Corporate Management Branch activities are currently underway to address lab facility management issues.

Recognition of the Lab Health & Safety Coordinator role and responsibilities varies between the 13 labs in its formality, with six on a volunteer basis, six with shared responsibility, and one with full time responsibilities.

Training for Lab Health & Safety Coordinators and Lab Health & Safety Committees

We found that training for Lab Health & Safety Coordinators is primarily on-the-job, and that while most lab health and safety committee members have received formal training, delivery and content of this training varies between labs. Committee training is currently being delivered by either an Area OHS Advisor or a Lab Health & Safety Coordinator, although responsibility for delivery of training is assigned to the NLHSC as per the LSM and the Agency's OHS Policy. Furthermore, tracking and monitoring of lab health and safety committee members training varies amongst the labs. There are many lab OHS courses for which no PeopleSoft code exists, such as formal lab committee member training delivered by Lab Health & Safety Coordinators.

Recommendation 9

The VP Human Resources Branch, in consultation with Science Branch and Corporate Management Branch, should

  1. clarify roles, responsibilities, and accountabilities, in support of the lab safety program;
  2. strengthen the reliability of the CPR by ensuring the tool includes requirements as expected per the LSM, the expectations for verification activities are sufficient and appropriate; and, that the CPR are carried out by trained individuals.

4.0 Appendices

Appendix A – Audit Criteria

Audit Objective: Provide assurance that the Agency has management controls in place in support of compliance with legal requirements of the Canada Labour Code Part II and related regulations, pertaining to OHS committees and health and safety representatives, training and awareness, hazard prevention, and lab safety.
Key OHS Legal Requirement Audit Criteria Audit Sub-Criteria
OHS Committees and Health and Safety Representatives 1. OHS Committees and Health and Safety Representatives are established and operate in compliance with legal requirements.
  1. OHS Committees and Health and Safety Representatives are established in accordance with the Canada Labour Code Part II.
  2. OHS Committees meet according to the frequency specified in the Canada Labour Code Part II.
  3. OHS Committees and Health and Safety Representatives receive key information to allow for effective monitoring of OHS objectives, strategies and results as required by legislation.
  4. The Agency has monitoring practices in place to help ensure OHS Committees and Health and Safety Representatives adhere to legislative requirements.
Training and Awareness 2. OHS training and awareness programs are in place and comply with legislative requirements.
  1. OHS training and awareness programs are in place.
  2. Training and awareness programs cover OHS roles, responsibilities and accountabilities.
  3. OHS training programs include hazard awareness and prevention measures and other legal requirements.
Hazard Prevention Program 3. A prescribed program for the prevention of hazards is developed, implemented and monitored.
  1. An implementation plan for the hazard prevention program is in place.
  2. A hazard identification and assessment methodology is in place.
  3. Hazards in the workplace are identified and assessed.
  4. Preventative measures to address the assessed hazard are in place.
  5. The effectiveness of the hazard program is evaluated.
Laboratory Safety 4. A prescribed program for Laboratory Safety is developed, implemented and monitored.
  1. A framework and supporting tools for lab safety exists and is established in accordance with the Canada Labour Code Part II.
  2. The lab safety self-assessment process is appropriately designed.
  3. The effectiveness of the lab safety program is evaluated.

Appendix B – Glossary

Agency
Canadian Food Inspection Agency
CFIA
Canadian Food Inspection Agency
COHSR
Canada Occupational Health and Safety Regulations
Corporate OHS
OHS and Prevention Division, Workforce and Workplace Relations Directorate, HRB, as the Agency's OHS functional lead
CLC Part II
Canada Labour Code - Part II Occupational Health and Safety
CPR
Continuous Performance Review
HOIR
Hazardous Occurrence Investigation Report
HPP
Hazard Prevention Program
HRB
Human Resources Branch
IFR
Injury Frequency Rate
JHA
Job Hazard Analysis
LSM
Lab Safety Manual
NLHSC
National Lab Health and Safety Coordinator
NOHS PC
National Occupational Health and Safety Policy Committee
OHS
Occupational Health and Safety
PPE
Personal Protective Equipment, Materials, and Devices
ToR
Terms of Reference
VP
Vice-President

Appendix C – Management Response and Action Plan

Management Response

  • The Audit of Occupational Health and Safety has been reviewed in detail by the VP Human Resources, the Executive Director Workforce/Workplace Relations Directorate, the A/National Manager, Occupational Health, Safety (OHS) and Corporate OHS Team. All reviewers fully support the audit report findings and recommendations and thank the Audit and Evaluation team for their thorough and detailed review in this matter.
  • The Agency is in the last steps of centralizing the OHS function and, in consultation with the National Occupational Health and Safety Policy Committee (NOHS PC), is working to establish and implement a comprehensive National OHS Program that fully meets all legislative requirements and the Agency's specific needs. Education and training for OHS representatives, committee members, and all employees will be a key component of that Program. The Audit provides us with information to better understand the status quo and situation in the Areas as our "base line", and further provides solid recommendations to help enhance our program. With this information we can readily monitor and measure our progress and anticipated results.
  • The Human Resources Branch, in consultation with the NOHS PC, Senior Management Committee, and our clients and key stakeholders, commits to undertake the required action to implement the recommendations outlined in the audit.
  • Recommendations will be implemented in accordance with Part II of the Canada Labour Code, Canadian Occupational Health and Safety Regulations, the National Joint Council Directive on Occupational Health and Safety, other applicable standards (CSA, ANSI) and recognized industry standards.
  • The NOHS Policy Committee, Area and Regional OHS Policy Committees, Workplace OHS Committees and Health and Safety Representatives will be consulted as appropriate during the development and implementation of the actions to be taken to implement the recommendations.

Management Action Plan

Recommendation 1
1. The VP Human Resources Branch should ensure that Corporate OHS fulfills its roles and responsibilities as functional lead for OHS, in support of compliance with legal and other requirements, including
  1. the development and implementation of a standard methodology to determine where there should be a work place health and safety committee or health and safety representative;
  2. ensuring committees and health and safety representatives are performing their legally required duties; and,
  3. coordinating, monitoring and reporting on the National OHS program.
Proposed Management Actions Responsible Official(s) Implementation Date
a) Review Canada Labour Code (CLC) requirements for committee and health and safety representatives and definition of "workplace" and consider control of workplace. Develop a National standard in consultation with NOHS PC, and once approved by appropriate Agency Governance, distribute through OHS Governance Network. (Note: Formation of committees is currently done in accordance with Part II of the CLC). VP HR, ED WWRD, Ntl Mgr OHS, and Corporate OHS a) May 2015
b) Develop appropriate OHS Committee standards, protocols and documentation requirements (in accordance with Legislation) to include: structure, role, reporting, documentation and record keeping. Corporate OHS to implement internal (HR) oversight functions to monitor, evaluate and report compliance with standard. Appropriate training to be developed and implemented to reflect standards. Ntl Mgr, OHS and Corporate OHS b) July 2015
c) Develop appropriate National OHS Program including oversight processes, to include internal (Corporate OHS) functions to monitor, evaluate and report compliance with CLC Part II and OHS program. Appropriate training to be developed and implemented to reflect standards. VP HR; ED WWRD; Ntl Mgr OHS and Corporate OHS c) October 2015
Recommendation 2
The VP HR Branch should ensure that the training materials developed for OHS committees and Health and Safety representatives provide for a consistent base of knowledge and awareness in support of effectively carrying out their roles and responsibilities under CLC Part II and topics identified by the Agency.
Proposed Management Actions Responsible Official(s) Implementation Date
A Training Directive was issued in April 2011, and will be used as an initial resource of information to help implement this recommendation.
a) Develop training guidelines, and requirements, outlining goals, learning objectives and performance objectives, in accordance with the Training Directive for OHS Committees and Health and Safety Representatives, and in consultation with National OHS Policy Committee, OHS Governance and Learning Division. VP HR, ED WWRD, Ntl Mgr OHS, and Corporate OHS a) May 2015
b) Develop core training material including expected learning. Management in consultation with the National OHS Policy Committee has ongoing processes for determination of mandatory training requirements. Learning Division is also involved in the development and implementation of training. Ntl Mgr OHS, Corporate OHS, ED WWRD b) October 2015
c) Secure any required governance approvals for training materials and implement core training material. ED WWRD; VP HR; Ntl Mgr OHS c) November 2015
d) Evaluate training compliance (using record keeping in PeopleSoft) and effectiveness through review of OHS Committee minutes, and regular audit of committee records and other documentation by Corporate OHS. Ntl Mgr OHS and Corporate OHS d) November 2016
Recommendation 3

The VP HR Branch should develop and implement a common approach to the identification of training needed and tracking of training taken by OHS committee members, health and safety representatives and Agency employees to ensure they receive training in health and safety as required by CLC Part II.

Proposed Management Actions Responsible Official(s) Implementation Date
A Training Directive was issued in April 2011 and will be used as a source of information to assist in implementing this recommendation.
a) Confirm common training guidelines, and requirements, learning goals and objectives for OHS Committee members, Health and Safety Representatives and Agency Employees in consultation with NOHS PC, OHS governance and Learning Division. [This process is currently underway in consultation with the NOHS PC] and with Learning Division. VP HR, ED WWRD, Ntl Mgr OHS and Corporate OHS a) May 2015
b) Develop standards and tools for tracking of training taken by above groups and implement. VP HR, ED WWRD, Ntl Mgr OHS and Corporate OHS b) October 2015
c) Evaluate training compliance (via record keeping in PeopleSoft or other tools, and effectiveness through review of OHS Committee minutes, and regular audit of committee records and other documentation by Corporate OHS. Continue annual tracking and evaluation. VP HR, ED WWRD, Ntl Mgr OHS and Corporate OHS c) November 2016
Recommendation 4
The VP Human Resources Branch should ensure that the Agency's HPP is in place and in sufficient detail to fully support meeting legal requirements. This should include expected methodology and processes for hazard identification and assessment.
Proposed Management Actions Responsible Official(s) Implementation Date
The Agency has developed and implemented a Hazard Prevention Program Directive.
a) The next step is the development of processes to assist worksites in the implementation of a HPP in accordance with the CLC and COHSR, which will be done in consultation with the NOHS PC. Suggested methodologies and processes for hazard identification are outlined in documentation available from HRSDC and will be integrated as appropriate. VP HR; ED WWRD, Ntl Mgr OHS, and Corporate OHS a) April 2015
b) Roll out implementation plan for HPP VP HR; ED WWRD, Ntl Mgr OHS, and Corporate OHS b) June 2015
c) Track and monitor initial and ongoing HPP implementation in accordance with CLC Part II. Natl Mgr OHS and Corporate OHS c) November 2015
Recommendation 5
The VP Human Resources Branch should clearly communicate national expectations for the implementation of hazard identification and prevention, monitor each Area's implementation of the HPP and report on the status of its implementation to Agency governance and NOHS PC.
Proposed Management Actions Responsible Official(s) Implementation Date
a) Develop appropriate tools to ensure HPP requirements and processes are communicated to all levels of the Agency. ED WWRD, Ntl Mgr OHS, and Corporate OHS a) May 2015
b) Reporting structure, timelines and evaluation criteria to be included in the HPP and communication strategy. ED WWRD, Ntl Mgr OHS, and Corporate OHS b) May 2015
c) Roll out communication strategy once approved and finalized (through OHS Governance Network). Ntl Mgr OHS and Corporate OHS c) Initial communication April 2015, ongoing communication as required
Recommendation 6
The VP HR Branch should ensure, based on the nature of the work place and the hazards associated with it, that minimum mandatory training and PPE requirements be developed, implemented and monitored for high risk work environments identified by the Agency.
Proposed Management Actions Responsible Official(s) Implementation Date
a) The implementation of an effective HPP will ensure that all work environments are evaluated and appropriate risks and hazards are identified. VP HR, ED WWRD, Ntl Mgr OHS and Corporate OHS a) June 2015
b) Results of HPP will provide information required to implement appropriate training recommendations and develop PPE standards for each workplace. VP HR, ED WWRD, Ntl Mgr OHS and Corporate OHS b) November 2015
c) Monitoring requirements of HPP and regular workplace inspections will ensure implementation of training and PPE will be evaluated on an annual basis commencing in April 2015 VP HR, ED WWRD, Ntl Mgr OHS and Corporate OHS c) November 2015
Recommendation 7
The VP HR Branch should reinforce employees' responsibility for formally recording and reporting hazardous occurrences including near misses to support compliance with CLC Part II.
Proposed Management Actions Responsible Official(s) Implementation Date
a) Develop and implement communication strategies to employees, Committees and Managers to ensure understanding of the requirement to report all hazardous occurrences (including near misses) and the importance of such reporting. ED WWRD; Ntl Mgr OHS and Corporate OHS a) May 2015
b) Develop and implement communication strategy to Committees and Managers outlining consistent process for reporting hazardous occurrences. ED WWRD; Ntl Mgr OHS and Corporate OHS b) May 2015
Recommendation 8
The VP Human Resources Branch, in consultation with Policy and Programs Branch and Operations Branch, should develop and implement processes to ensure OHS impacts and requirements are taken into consideration when new programs are being implemented or existing ones changed.
Proposed Management Actions Responsible Official(s) Implementation Date
a) Develop Inter-branch consultation processes and tools to ensure consideration of OHS impacts in discussions of new programs or changes to existing programs. Currently the changes are discussed and reviewed on an ad hoc basis. VP HR, ED WWRD, Ntl Mgr OHS a) June 2015
b) Seek required approval of, and implement, inter-branch consultation processes. VP HR; ED WWRD; Ntl Mgr OHS b) July 2015
Recommendation 9
The VP HR Branch, in consultation with Science Branch and Corporate Management Branch, should
  1. clarify roles, responsibilities, and accountabilities, in support of the lab safety program;
  2. strengthen the reliability of the CPR by ensuring the tool includes requirements as expected per the LSM, the expectations for verification activities are sufficient and appropriate; and, that the CPR are carried out by trained individuals.
Proposed Management Actions Responsible Official(s) Implementation Date
a) Lab Safety program will be updated to clarify roles, responsibilities and accountabilities, in consultation with Science Branch and Corporate Management Branch. VP HR, ED WWRD, Ntl Mgr OHS, Corporate OHS a) July 2015
b) Appropriate tools will be developed to implement the recommendation as outlined, in collaboration with the Laboratory EDs and Lab Safety Network. VP HR, ED WWRD, Ntl Mgr OHS, Corporate OHS b) July 2015
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