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Occupational Health and Safety Audit

Audit Report

Project No. 16/17 01–03

Prepared by
Audit and Evaluation Directorate

Table of contents

1.0 Summary

1.1 Audit objective

The purpose of the audit was to determine whether the Canadian Space Agency's (CSA) Occupational Health and Safety (OHS) program complies with the Canada Labour Code, Part II (CLC) and other current policies, guidelines and regulations.

1.2 Audit opinion

In our opinion, most of the requirements of the CLC, Part II and other current OHS policies, guidelines and regulations are being met at the CSA. However, some deficiencies involving moderate issues require management's attention.

1.3 Statement of assurance

As Chief Audit Executive, I am of the opinion that sufficient and appropriate audit procedures were followed and that audit evidence was collected to support the accuracy of the opinion provided in this report. This opinion is based on a comparison of the conditions, as they existed at the time of the audit, against the pre-established audit criteria determined in consultation with management. The opinion is applicable only to the entity examined. The evidence was gathered in compliance with Treasury Board's (TB) internal audit policy, directives and standards. The procedures followed are in accordance with the professional standards of the Institute of Internal Auditors. The evidence gathered is sufficient to convince senior management of the validity of the opinion derived from the internal audit.

1.4 Summary of findings

The audit of OHS practices revealed that CSA has made a number of improvements in recent years. In fact, an OHS Policy and a governance document setting out the roles and responsibilities have been developed. Some procedures have been reviewed and improved, while others are under revision. In addition, the CSA's various sectors have developed and implemented occupational health and safety plans or have put preventive measures in place to ensure people safety. Also, good practices pertaining to training and wellness have been implemented.

However, although an occupational health, safety and wellness framework was published on the Intranet, we found that the OHS Policy and the roles and responsibilities of the various OHS stakeholders had not been communicated to all employees.

With regard to the implementation of OHS programs required under the CLC, we found that the hazard prevention program (HPP) was developed and approved in spring . Following the development of the HPP, an action plan including corrective OHS measures was prepared and is currently being implemented. With respect to the provision of materials and equipment, some health and safety plans refer to this, and employees have the materials they need to do their work safely. However, no formal program has been devised as set out in the CSA's OHS Policy. With regard to workplace inspections, which are to be carried out at least once a year according to the CLC, we found that in , one of the three workplaces had only been 90% inspected, while information had not been compiled for another. In addition, some follow-ups on corrective action to be taken following the inspections were not done.

Recommendations were made and a management action plan was drawn up to address the identified deficiencies.

Original signed by the Chief Audit Executive

Signature of the Chief Audit Executive

Members of the audit team

  • Dany Fortin
  • Johanna Gailer

2.0 Audit report

2.1 Background

The departments must comply with federal OHS legislation, including the CLC, Part II and the Canada Occupational Health and Safety Regulations (COHSR), which clarifies the CLC. The regulations was made in , and its objective is to "prevent accidents and injury to health arising out of, linked with, or occurring in the course of employment." A Policy on Occupational Safety and Health have been issued by the TB. Its purpose is to promote a safe and healthy workplace for Public Service employee and to reduce the incidence of occupational injuries and occupational illnesses. The National Joint Council (NJC) also issued an Occupational Health and Safety directive that clarifies the regulation and sets out the specific obligations that apply solely to the federal government. In addition, the Government of Canada has put in place services and information about workplace wellness in order to create conditions favourable to strong employee engagement.

The CSA buildings are made up of offices, laboratories and warehouses.

2.2 Audit rationale, scope and approach

Rationale

This audit project was included in the - Risk-Based Audit Plan approved by the CSA Audit Committee (AC).

The rationale for this project is that the Occupational Health, Safety and Wellness Framework has a significant impact on all CSA sectors and that there are legal obligations attached to it. In addition, the most recent occupational health and safety audit was in , with follow-up on the implementation of actions in .

Scope

The audit focused on the CSA's Occupational Health, Safety and Wellness Framework procedures, processes and activities. OHS and wellness information produced since , was examined. The audit covered the John H. Chapman Centre in St-Hubert, the David Florida Laboratory (DFL) in Ottawa and the Gatineau office.

Approach

The audit criteria were established on the basis of requirements drawn from acts, regulations and policies. The criteria and sub-criteria are shown in Appendix A. The audit had involved various processes, including interviews and document reviews.

We have:

  • Interviewed 33 CSA employees (employees, supervisors, managers, directors, directors general and OHS committee members);
  • Examined six inspection reports;
  • Examined two investigation reports.

It should be noted that the audit objective and criteria were discussed with the audited entity.

2.3 Findings, recommendations and management's reactions

Expected outcomes

Criteria 1, 2, 3 and 4

In order to determine whether the CSA's OHS program complies with the Canada Labour Code (CLC) Part II and other current directives and regulations, we expected to find the following elements:

  • An OHS activities management framework
  • OHS monitoring and control procedures
  • Accountability for OHS activities
  • Best practices with regard to wellness

2.3.1 Governance

Audit objective: The purpose of the audit project was to determine whether the CSA's OHS program complies with the CLC, Part II and other current policies, guidelines and regulations.

Findings
Criterion 1

An OHS activities management framework is in place at the CSA.

Conditions

Conclusion on the criterion

Our audit showed that the OHS activities framework complies in large part with the CLC, Part II and other current guidelines and regulations. However, some deficiencies were identified.

Roles and responsibilities are defined and applied

OHS policy

An OHS policy and governance document describing the organization's OHS roles and responsibilities in detail were produced and approved by the CSA executive committee in . These documents clearly set out the organization's objectives and the accountability framework with regard to health and safety functions. Although the CSA has not communicated these documents to employees, it has published an occupational health and safety framework on its intranet site. The framework gives the broad strokes of the CSA's OHS Policy. The fact that the policy and governance document have not been shared with employees emerged during interviews conducted as part of this audit. In fact, a number of employees mentioned that they would like the CSA to more clearly specify what is expected of them in terms of OHS, in part by clarifying their roles and responsibilities with regard to developing and approving health and safety plans, addressing issues identified during inspections, and the role of OHS coordinator.

Policy committee and Workplace committees

The CLC requires that the employer set up a Policy Health and Safety Committee (PHSC) , as well as Workplace Health and Safety Committees (WHSC). The CSA complies with this requirement. The organization has a PHSC and three WHSC (St-Hubert, Gatineau, and DFL). The CLC sets out the roles and responsibilities of the committees. It mentions that PHSC participates in the development of health and safety policies and programs and WHSC participate in all of the inquiries, investigations, studies and inspections pertaining to the health and safety. The CLC also states that the PHSC considers and expeditiously disposes of matters concerning health and safety raised by members of the committee or referred to it by a workplace committee. We found that the WHSC annual reports containing issues raised in had not been submitted to the PHSC. To ensure compliance with the CLC and effective governance of OHS issues, the annual reports and issues raised by the WHSC should be presented to and periodically discussed by the PHSC.

A further CLC requirement is that the PHSC must meet at least once every quarter. The committee officially met only once in -. The reason given was the members' lack of availability. Quorum was not met once the meetings were set up. The situation improved in -, when the PHSC met quarterly as required by the CLC.

OHS programs are in place

Programs

The CLC requires that a hazard prevention program (HPP) be developed and implemented and that if needed, a program for the provision of personal protective equipment, clothing, devices or materials be put in place. We noted that an HPP was developed and approved in spring . Following the development of the HPP, a hazard identification and assessment process was done and an action plan including corrective OHS measures was developed and is being implemented. Full implementation is expected to be completed in .

All CSA employees have access to the required personal protective materials, equipment, devices or personal protective clothing to ensure their safety in the workplace and, in a number of cases, procedures are in place for their use. Moreover, information on the equipment can be found in some OHS plans. As stated in the CSA's OHS Policy, it is planned that a formal program for the provision of personal protective equipment, clothing, devices or materials be developed.

Occupational Health and Safety Plans

Various CSA sectors have developed and implemented occupational health and safety plans or have put in place the required preventive measures to ensure the security of the premises and individuals. However, we noted that some occupational health and safety plans that were developed or updated by the sectors were never approved.

Other CLC requirements

The CSA takes steps to ensure that all structures and buildings comply with regulatory standards.

The CLC also sets out certain requirements with regard to first aid, ergonomics and hazardous materials. We found that the CSA complies with these requirements. With regard to first aid, it provides first aid facilities for its employees. In terms of ergonomics regulatory standards, we found that CSA employees have resources at their disposal. According to its OHS Policy, the CSA plans to develop formal ergonomics and first-aid programs. We also noted that the CSA meets CLC requirements regarding hazardous materials. To control hazardous materials, the CSA uses a computerized system that makes it possible to inventory and have a material safety data sheet for all hazardous product. This system is updated every time a change is made to a product.

With regard to preventing violence in the workplace, we found that the CSA has a Policy and Procedure on the Prevention and Resolution of Harassment in the Workplace. In addition, a Workplace Violence Prevention Policy was developed during the year and approved in . Implementing this policy will allow the CSA to meet all CLC and Canadian Occupational Health and Safety Regulations (COHSR) workplace violence requirements.

We also found that some sectors have developed procedures to guide certain types of specialized work, such as work-at-heights, confined space and lock-out. The CSA worked with a consultant to review this procedures and establish formal programs. The draft documents of three programs have been developed, namely the Lock-out Program, the Confined Spaces Program and the Material Handling program.

OHS hazards and risks are identified and the necessary preventive measures are in place

As stated previously, CSA's various sectors have developed and implemented occupational health and safety plans or have put the required preventive measures in place to ensure the safety of premises and individuals. In addition, all hazards present at the CSA have been inventoried and identified by hazard type in the hazard prevention program.

With regard to contractors carrying out work at the CSA, we found that they have documentation at their disposal that identifies hazards and preventive measures. Depending on the location and type of work, contractors are given training and are required to sign a document certifying that they have received the training and are familiar with the hazards and risks associated with the work they have to do. We also observed that since last year, the CSA has been hiring outside specialized OHS firms to oversee construction sites where work is being carried out by contractors.

Employees receive required OHS training

We found that CSA employees receive the required OHS training. Employees and supervisors are required to take mandatory training. In addition, supervisors ensure that their employees have the required competency certificates as proof that they received the training. For example, in order to work-at-heights, an employee must have received the appropriate training. If an employee does not have his competency certificate, he is not allowed to work on the scaffolding. We also found that some work locations have official training registers. Over the coming year, the CSA plans to produce a single register of mandatory OHS training for all employees and workplaces, in order to facilitate access to the information for the CSA as a whole.

With regard to contactors, they are required to have current competency certificate showing they have the qualifications needed to carry out the work. Training requirements are set out in the request for proposals and must be demonstrated in the bids. For one of the three CSA workplaces, contractors must also receive OHS training on CSA premises prior to beginning the work.

Relevant OHS information is communicated and posted

The CSA communicates information and carries out employee OHS awareness campaigns by email, on the Intranet site and on the bulletin boards.

A number of CLC requirements with regard to posting are met, such as posting the CLC, Part II and printed regulatory. However, some shortcomings have been noted. The OHS Policy and annual WHSC report for one workplace were not posted as required by the CLC. In addition, at the time of the audit, the posted list of one workplace's committee members and representatives was not up to date. This was recently corrected. We also noted that the responsibility for posting was not clearly defined in the roles and responsibilities of the various OHS stakeholders.

Recommendations
  1. Communicate the OHS Policy, the governance document describing the roles and responsibilities, and any other OHS information to employees, as required by the CLC.
  2. Finalize the implementation of the action plan stemming from the hazard prevention program (HPP) and develop a safety equipment and materials provision program.
  3. Ensure that health and safety plans are approved.
Responsibility identified
Organization

Corporate Services and Human Resources Directorate

Function

Executive Director, Corporate Services and Human Resources

Management's response

We concur with the report's recommendations.

Management action plan
Action plan details
  1. The OHS Policy was adjusted to take into account the TBS Policy Reset Initiative and the CSA's OHS program standardization initiative. A consultation will be held with the health and safety committees and the document will subsequently be shared with employees. Deadline:
  2. Complete the implementation of measures set out in the corrective action plan stemming from the Occupational Health and Safety Hazard Prevention Program (OHSHPP), including developing the safety equipment and materials provision program. Deadline:
  3. Implement a procedure to confirm approval of health and safety plans. Deadline:

2.3.2 Monitoring and control

Audit objective: The purpose of the audit project was to determine whether the CSA's OHS program complies with the CLC, Part II and other current policies, guidelines and regulations.

Findings
Criterion 2

OHS monitoring and control procedures are implemented.

Conditions

Conclusion on the criterion

Our audit showed that overall, OHS monitoring and control procedures are in place and comply with current directives and regulations. However, some deficiencies were identified.

Monitoring of OHS practices is performed on an ongoing basis

The CLC states that WHSC should inspect each month all or part of the work place, so that every part of the work place is inspected at least once each year. For , we found that workplace inspections had been 100% carried out in one workplace, 90% in a second, and the information for the third workplace had not been compiled. The reasons given for this non-compliance with the CLC requirement were lack of time and limited access to the premises. For , as of , some improvement was noted; however, some elements need to be finalized to achieve full compliance with the CLC in this regard.

An inspection procedure and tools such as inspection grids are available. However, the inspectors do not perform the inspections consistently, and the use of the grids varies from one inspector to another.

Once the inspections are completed, the recommendations are issued and an action plan developed to address instances of OHS non-compliance or identified areas of improvement. We found that for two of the workplaces, the workplace committee had followed up on the action to be taken following inspections. However, in one workplace where certain corrective action had been taken, no information was available for some problematic situations identified, so we could not determine if these had been addressed. It should be noted that for , none of the problematic situations identified was classified as being high-risk for workers.

A formal process for managing complaints, incidents and accidents is in place and investigations are carried out by qualified individuals

We found that a formal process for managing complaints, incidents and accidents is in place and that investigations are carried out by qualified individuals. A review of the investigation process made it possible to note that very few incidents and accidents occur each year in CSA workplaces. We found that a new procedure was put in place in , that the tools are available to the employer and employees when an investigation must be performed, and that the procedure is easily accessible.

Recommendations
  1. Inspect 100% of workplaces annually.
  2. Remind inspectors of the importance of following established procedure and using the available tools to carry out workplace inspections, in order to ensure the quality of the inspections.
  3. In a timely manner, follow up on the corrective actions to be taken following inspections.
Responsibility identified
Organization

Corporate Services and Human Resources Directorate

Function

Executive Director, Corporate Services and Human Resources

Management's response

In agreement with recommendations.

Management action plan
Action plan details
  1. Confirm the inventory of premises and put in place a system of periodic follow-up on the progress of annual inspections with workplace OHS committees to ensure 100% coverage of the workplaces to be inspected. Deadline:
  2. Reminder to involved stakeholders regarding the inspection procedure and available tools to use. Deadline:
  3. Implementation of a system to follow up on corrective action to be taken following inspections. Deadline:

2.3.3 Accountability

Audit objective: The purpose of the audit project was to determine whether the CSA's OHS program complies with the CLC, Part II and other current policies, guidelines and regulations.

Findings
Criterion 3

OHS activities are subject to accountability.

Conditions

Conclusion on the criterion

Our audit showed that OHS activities are subject to accountability, in compliance with requirements.

OHS outcomes are reported in accordance with the requirements of Employment and Social Development Canada's (ESDC) Labour Program

We found that the CSA meets accountability requirements. The WHSC produced annual reports, and the PHSC produced minutes following its meetings. In addition, the employer's annual report for hazardous occurrences and reports following investigations were produced. An Assurance of Voluntary Compliance form was ratified by the CSA in , following the general OHS inspection conducted by the Labour Program. All the documents mentioned above were sent to ESDC – Labour Program, as required.

The progress made following the implementation of work plans is communicated

We found that a work plan for the CSA's hazard prevention program was developed in -. Once a month, an HPP report is submitted to the CSA director general of Corporate Services. Periodic update and follow-up meetings with the DGs have been held since to discuss occupational health and safety.

However, we noted that there is no work plan that encompasses all the various elements of the CSA's OHS program that are in the process of being implemented. Because several programs and procedures are being developed or reviewed, an overall work plan for all OHS components in development would make it possible to more readily track implementation progress for the various elements and facilitate periodic reporting to OHS committees and senior management.

Recommendations

N/A

Responsibility identified
Organization

Corporate Services and Human Resources Directorate

Function

Executive Director, Corporate Services and Human Resources

Management's response

N/A

Management action plan
Action plan details

N/A

Deadline: N/A

2.3.4 Wellness

Audit objective: The purpose of the audit project was to determine whether the CSA's OHS program complies with the CLC, Part II and other current policies, guidelines and regulations.

Findings
Criterion 4

Best practices with regard to wellness are implemented and are subject to accountability.

Conditions

Conclusion on the criterion

Our audit showed that best practices with regard to wellness are implemented and are subject to accountability.

Training, information and activities related to wellness are offered to employees

The CSA began implementing best practices with regard to wellness approximately a decade ago. It bases its practices on the "Brain Friendly" approach and key neuroscience concepts. We found that CSA employees receive information on wellness via emails, posts on CSA bulletin boards and the intranet site. Information topics include mental health and wellness, the Employee Assistance Program, the Brain Friendly Health and Wellness Program, Health and Wellness Learning Day (HWLD), awareness capsules, and healthy workplace, to name a few. We found that non-mandatory training is also offered to employees as part of wellness best practices. Employees can also take awareness workshops and mental health first-aid training. In addition, the CSA offers a number of wellness activities to employees, such as the twice-yearly wellness competition, the "couch to 5K" activity, and meditation audio capsules. We also noted that two programs in the CSA's OHS and wellness framework were put in place, namely the Health and Wellness Program and the Disability Management and Return to Work Program.

Wellness outcomes are reported in accordance with requirements

We found that the wellness outcomes were being reported in accordance with requirements. The CSA reports on wellness and mental health in the "People Management" component of the Management Accountability Framework (MAF).

In addition, once a month, a report on the Health and Wellness Program is produced and submitted to the Director General, Corporate Services.

Recommendations

N/A

Responsibility identified
Organization

Corporate Services and Human Resources Directorate

Function

Executive Director, Corporate Services and Human Resources

Management's response

N/A

Management action plan
Action plan details

N/A

Deadline: N/A

Appendix A – Terms of reference

Audit objective: The purpose of the audit project was to determine whether the CSA's OHS program complies with the CLC, Part II and other current policies, guidelines and regulations.

Audit criteria Audit sub-criteria
  • Sub-criterion met 
  • Sub-criterion partly met 
  • Sub-criterion not met 
Criterion 1
An OHS activities management framework is in place at the CSA.
Sub-criterion 1.1: The roles and responsibilities pertaining to maintaining and reviewing the OHS program are established and applied. Sub-criterion partly met
Sub-criterion 1.2: The OHS programs required by the Canada Labour Code and other current guidelines and regulations are implemented. Sub-criterion partly met
Sub-criterion 1.3: OHS hazards and risks are identified. Sub-criterion met
Sub-criterion 1.4: The required protective and preventive measures are implemented. Sub-criterion partly met
Sub-criterion 1.5: Employees receive the required OHS training. Sub-criterion met
Sub-criterion 1.6: Relevant OHS information is communicated and posted. Sub-criterion partly met
Criterion 2
OHS monitoring and control procedures are in place.
Sub-criterion 2.1: Ongoing monitoring of OHS practices is carried out. Sub-criterion partly met
Sub-criterion 2.2: A formal process for managing complaints, incidents and accidents is in place, and investigations are carried out by qualified individuals. Sub-criterion met
Criterion 3
OHS activities are subject to accountability
Sub-criterion 3.1: OHS findings are reported in accordance with the requirements of the Employment and Social Development Canada (ESDC) Labour Program. Sub-criterion met
Sub-criterion 3.2: Progress made following the implementation of the work plans are communicated. Sub-criterion met
Criterion 4
Wellness best practices are in place and are subject to accountability.
Sub-criterion 4.1: Wellness training, information and activities are offered to employees. Sub-criterion met
Sub-criterion 4.2: Wellness results are reported in accordance with requirements. Sub-criterion met
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