Audit of Health and Safety System Administration
- Executive summary
Findings and recommendations
- Objective 1: To provide assurance that the health and safety unit efficiently and effectively enables the Canadian Grain Commission to meet its health and safety goals
- Objective 2: To evaluate the effectiveness of the Canadian Grain Commission's hazard prevention program in accordance with section 19.7 of the Canada Occupational Health and Safety Regulations
- Acknowledgements and contacts
Health and safety policy at the Canadian Grain Commission is established and overseen by a national committee with management, employee, and union representation. The Canadian Grain Commission also has a small health and safety unit within the Human Resources division. This unit leads the implementation of policies and helps management and employees manage their day-to-day health and safety obligations. These obligations are set out in the Canada Labour Code Part II and the Canada Occupational Health and Safety Regulations. Along with various safety and health committees, the health and safety unit supports employees and managers across the country who work in a wide range of potentially hazardous environments, including offices, laboratories, and grain terminals.
Audit and Evaluation Services audited the administration of the Health and Safety System to provide assurance that the health and safety unit efficiently and effectively enables the Canadian Grain Commission to meet its health and safety goals. The audit was performed in conjunction with an external evaluation of the effectiveness of the Canadian Grain Commission's hazard prevention program. Human Resources requested the evaluation, which was performed by a qualified third party. The results were provided to management and the policy committee in a separate report.
The audit fieldwork took place from September 2017 to February 2018. Audit and Evaluation Services tested relevant data and activities from April 2015 to September 2017. All Canadian Grain Commission work locations were included in the scope of the audit.
The Canadian Grain Commission has a strong health and safety culture which was evident through interviews with employees, management, and health and safety unit staff. Day-to-day health and safety matters are being addressed, but the health and safety unit has a small team. This causes the Canadian Grain Commission to often take a reactive, rather than strategic, approach to health and safety plans. The audit also identified monitoring and updating of employee training as an area that needs improvement. Significant findings in this report include the following:
- updated health and safety policies need to be completed, approved and communicated to employees as soon as possible
- the performance of the workplace occupational health and safety committees is not being monitored against the policy and legislative requirements
- employee training records were not complete, and refresher training schedules and programs have not been defined
- deficiencies in the hazard prevention program identified in the evaluation must be prioritized and remediated to ensure compliance with the Canada Occupational Health and Safety Regulations
Management has committed to appropriate actions to address the findings above as well as the other opportunities for improvement identified during the audit. For certain findings, management has developed alternative action plans to the audit recommendations to improve their controls. Audit and Evaluation Services believes management has carefully considered their action plans and has committed to actions that are achievable.
Due to the large number of individual items (including those from the hazard prevention program evaluation report) requiring action by the health and safety unit and committees, timelines for completion are scheduled over the next three fiscal years. Management has used the impact rating in this report to prioritize the action plan. Audit and Evaluation Services supports the rationale applied by management to schedule implementation of these action plans.
Statement of assurance
In the professional judgment of the Chief Audit Executive, sufficient and appropriate audit procedures have been conducted and evidence gathered to support the accuracy of the opinion provided in this report. The opinion is based on a comparison of the conditions as they existed at the time, as described in the audit scope, against pre-established audit criteria. The opinion is applicable only to the activity examined.
The audit approach and methodology conform with the International Standards for the Professional Practice of Internal Auditing as defined by the Institute of Internal Auditors and the Directive on Internal Audit, as required by the Treasury Board Secretariat's Policy on Internal Audit.
Authority for audit
The mission of the internal audit function of Audit and Evaluation Services is to provide independent and objective assurance services designed to add value and improve the Canadian Grain Commission’s operations. Internal audit helps the Canadian Grain Commission accomplish its objectives by using a systematic, disciplined approach to assess and improve the effectiveness of risk management, control and governance processes. An overview of internal audit’s purpose, authority and responsibilities is provided in the Canadian Grain Commission’s Internal Audit Charter.
Audit and Evaluation Services included the audit of Health and Safety System administration in the risk-based audit plan for 2017 to 2020. The Departmental Audit Committee recommended approval of the audit to the Chief Commissioner in May 2017.
The day-to-day health and safety functions at the Canadian Grain Commission are the responsibility of the health and safety unit within the Human Resources division. Employees conduct their duties in various work environments across Canada including offices, laboratories, and grain elevators, where they may be exposed to physical, chemical, and biological hazards. Management, supported by the health and safety unit, is accountable for ensuring all employees are equipped with proper resources and are aware of the importance of occupational safety and health. The Canadian Grain Commission must also have established monitoring processes to ensure all employees have sufficient knowledge and education about potential risks within their environment.
Workplace health and safety requirements are established in the Canada Labour Code Part II, with additional requirements set out in the Canada Occupational Health and Safety Regulations. The National Occupational Safety and Health (NOSH) policy committee and Workplace Health and Safety Committees support health and safety governance in the regions and at headquarters. These committees have union, management, and employee representation.
The health and safety unit supports the implementation of health and safety requirements by
- liaising with regulatory bodies, central agencies and employee representatives about occupational safety and health matters
- providing functional direction and advice to management and occupational safety and health committees
- participating in the development, implementation and monitoring of prevention and educational programs
- monitoring the occupational safety and health program by reviewing accident investigation reports, statistical reports, workplace inspection reports, meeting minutes of safety and health committees, and safety audit reports
The Audit of Health and Safety System Administration contains two parts: an internal audit of how the health and safety system is administered and an assessment of the effectiveness of Canadian Grain Commission’s hazard prevention program. The hazard prevention program was evaluated by a qualified third party, Workplace Safety & Prevention Services, and a separate report was issued to Canadian Grain Commission management.
This audit engagement had two objectives:
- To provide assurance that the health and safety unit efficiently and effectively enables Canadian Grain Commission to meet its health and safety goals
- To evaluate the effectiveness of Canadian Grain Commission’s hazard prevention program in accordance with section 19.7 of the Canada Occupational Health and Safety Regulations
The scope of the audit of Health and Safety System Administration included administrative activities and processes performed by the health and safety unit for the time period of April 2015 to September 2017. We reviewed work locations including headquarters, the Grain Research Laboratory, and regional offices (including laboratories and grain terminals). During audit testing, we reviewed the following:
- administration of current health and safety programs
- policies and guidance material
- training programs
- NOSH committee and Workplace Health and Safety Committee meeting minutes
- interviews with a selected sample of employees, supervisors, and managers
Workplace Safety & Prevention Services evaluated the hazard prevention program against the requirements set out by the Regulations.
As the internal auditors are not qualified health and safety professionals, actual safety hazards were not evaluated for this administrative audit.
Approach and methodology
The audit methodology used by Audit and Evaluation Services is based on guidance provided by the Institute of Internal Auditors and the Office of the Comptroller General of Canada. The standards for internal audits are articulated in the IIA’s International Professional Practices Framework and the Treasury Board Secretariat’s Policy on Internal Audit.
Findings and recommendations
Objective 1: To provide assurance that the health and safety unit efficiently and effectively enables the Canadian Grain Commission to meet its health and safety goals
1.1 Roles and responsibilities
After interviewing and observing numerous Canadian Grain Commission employees, directors, and managers during their evaluation, Workplace Safety & Prevention Services stated that, "The Canadian Grain Commission presents with a strong safety culture observed at all levels of the organization despite the fact that Canadian Grain Commission has to face various workplace hazards and challenges imposed by waterfront activities and scientific labs work."Footnote 1 This observation indicates awareness that all staff are responsible for aspects of health and safety. However, the organization also assigns specific accountability. Part II of the Code sets out defined roles for the NOSH committee, the Workplace Health and Safety Committees, and the health and safety unit.
We analyzed the activities of the health and safety unit to determine if their role was clear. The unit staff's understanding of their responsibilities is consistent with the responsibilities outlined by the manager. When interviewed, employees said they were satisfied with the service and expertise provided by the unit. The unit is perceived mainly as a service provider that helps units or divisions complete health and safety tasks. The unit is also known for providing guidance to managers, supervisors, employees and the Workplace Health and Safety Committees on specific issues.
The health and safety unit maintains a relatively low profile within the organization. Health and safety staff do not typically make presentations to groups of employees or managers (other than training sessions), issue all-staff emails, or host awareness events. All health and safety employees are located in the headquarters building, which is comprised of offices and the Grain Research Laboratory. More than half of the Canadian Grain Commission’s employees work in the eastern and western regions. The majority of those staff work in an industrial environment (grain elevators).
As a result of location, employees at headquarters were more likely to interact directly with the health and safety unit and report issues to them immediately. In the regions, employees reported that they generally dealt with health and safety situations through the regional management teams and/or their local Workplace Health and Safety Committees before reporting the situation to the health and safety unit. However, regional employees – who are not part of the health and safety unit – may not have sufficient or updated training. This may result in inappropriate responses to incidents as well as incomplete central tracking and reporting. Some of the potential consequences are mitigated by the activities of the Workplace Health and Safety Committee; however, the committee does not replace a trained and/or designated health and safety professional for making time-sensitive decisions. More regional presence of health and safety staff could increase their profile and make staff more likely to contact them immediately in health and safety situations.
Like many small units, health and safety staff have a large number of administrative tasks to perform in addition to their operational duties. They spend a limited amount of time on annual or long-term planning and program development. They are often asked to advise on immediate but relatively low-risk health and safety situations that occur at headquarters, which can interrupt work on other assignments. As a result, health and safety’s overall operational approach is reactive rather than strategic.
The health and safety unit has not performed an assessment of relative risk to determine how their time should be allocated. For example, proper ergonomics are important for employees in all locations. However, through interviews it became clear that they spend more time on ergonomic assessments and related procurement at headquarters than they do on potentially higher-risk areas such as terminal grain elevators in the regions. The reactive approach also reduces the unit’s efficiency due to disruption of work. Better organization of work and adding resources could create more time for completing priority initiatives. One common approach is contracting ergonomic assessment work to a third party, as it is a largely generic health and safety issue.
Recommendation 1: risk assessment
We recommend that the manager of health and safety assess tasks and determine the relative risk that they pose if not actioned, then prioritize the tasks and assign the appropriate level of resources to work on them. Tasks should include ongoing work as well as individual projects or initiatives.
Based on this assessment, human resources management should review the capacity of health and safety staff to adequately provide service to regional areas. If necessary, management should adjust travel or other resources to increase service to the regions. A thorough review should include the potential for contracting with external parties to provide specific services when feasible.
The NOSH committee is the overall policy committee required by Part II of the Code. Operations-level activities are carried out by the Workplace Health and Safety Committees. The Canadian Grain Commission has six Workplace Health and Safety Committees across Canada, two of which are located in Winnipeg. These committees are consultation groups made up of representatives from the union, management and employees. We reviewed the activities of these committees for compliance and effectiveness. We also reviewed the NOSH committee meeting minutes for the audit period.
According to Part II of the Code, Workplace Health and Safety Committees must
- "participate in all of the inquiries, investigations, studies and inspections pertaining to the health and safety of employees, including any consultations that may be necessary with persons who are professionally or technically qualified to advise the committee on those matters" Footnote 2
- "inspect each month all or part of the workplace, so that every part of the work place is inspected at least once each year" Footnote 3
All workplace inspections are recorded in the committee meeting minutes. Through testing, we determined that not all of the Canadian Grain Commission work sites were inspected every year from 2015 to 2017.
We assessed the factors listed in the table below to determine how effective the Workplace Health and Safety Committees are in meeting the Code requirements.
|Workplace Health and Safety Committees||Headquarters (Winnipeg)||Grain Research Laboratory (Winnipeg)||Vancouver (Western Region)||Calgary, Prince Rupert, Weyburn, Saskatoon (Western Region)||St. Lawrence (Eastern Region)||Thunder Bay, Chatham/ Hamilton (Eastern Region)|
|Number of meetings per year|
|50% non-management members|
|Training requirements for members met (based on sample of 2 members for each committee)|
|0 out of 2||0 out of 2||1 out of 2||1 out of 2||0 out of 2||0 out of 2|
|Evidence of issues resolved and subsequently closed on meeting minutes (for items completed at time of audit)|
From the above table, we made the following observations:
- Part II of the Code requires the Workplace Health and Safety Committees to meet at least nine times each year Footnote 4, which was not consistently achieved
- the committees fulfilled the requirement that at least half of the committee members be employees who do not exercise managerial functions Footnote 5
- the committees were diligent in following up on identified health and safety issues, although often documentation could be improved
Part of the committees’ function is to confirm that health and safety issues identified through workplace inspections or employee reports are appropriately addressed. We tested a sample of meeting minutes from each committee to determine if they were fulfilling this function. In our review of minutes, we noted that different formats were used for each Workplace Health and Safety Committee’s records. The lack of consistency made it difficult to trace some issues through to completion. We determined that more than 30% of the issues chosen for our sample were not appropriately closed in the minutes. The committee co-chairs were sufficiently knowledgeable about the outstanding issues and were able to provide information on each one. Each outstanding issue was either completed but not closed in the minutes or was an ongoing issue that remained open.
Through interviews, we determined that there is no established collaboration between the Workplace Health and Safety Committees and the NOSH committee and limited or no collaboration between individual Workplace Health and Safety Committees. The staff of the health and safety unit provide a common link as participants or observers of each committee. However, periodic sharing between Workplace Health and Safety Committees could make the committees more effective. For example, committees could share good practices for conducting workplace inspections, meetings, taking minutes, or resolving similar issues.
We also found that the Workplace Health and Safety Committee chairs did not feel they were engaged with the NOSH committee. While they were often asked to contribute specific information for planning or executing initiatives, they were not involved in determining the initiatives and action plans. The Workplace Health and Safety Committees received most of their information about the NOSH committee through approved NOSH committee minutes.
Workplace Health and Safety Committee chairs also identified a degree of disengagement with operational activities of the health and safety unit. Periodic visits by health and safety staff were typically associated with a specific task, and there were no general meetings where the Workplace Health and Safety Committee members learned about the health and safety unit’s goals, plans and initiatives. Better integration and communication between the NOSH committee, Workplace Health and Safety Committees, and the health and safety unit could foster better overall engagement within the Canadian Grain Commission’s health and safety network.
Recommendation 2: Workplace Health and Safety Committee performance
We recommend that the health and safety unit monitor the performance of the Workplace Health and Safety Committees against the requirements of Part II of the Code and report the results to senior management. Non-compliance should be investigated and resolved as soon as possible.
Recommendation 3: collaboration
We recommend that the Workplace Health and Safety Committees create a centralized log for tracking and monitoring committee action items. The log would encourage sharing between committees and allow them to identify similar issues.
We also recommend that the Workplace Health and Safety Committees establish a periodic (e.g. annual) forum for sharing information and good practices. The forum could also be an opportunity to increase interaction with the health and safety unit and the NOSH committee. The committees should consider using virtual meeting technology to facilitate these forums.
1.3 Policies, training and programs
Policies are an important method for communicating health and safety procedures, expectations, and responsibilities to individuals visiting or working on Canadian Grain Commission premises. Together with the NOSH committee, the health and safety unit is responsible for developing and renewing the Canadian Grain Commission's occupational health and safety policies.
During the audit we were provided with draft policies that were created in 2016 and 2017 but were not yet approved or published. The most recent policies available on the internal website were significantly outdated. For instance, the overarching Occupational Health and Safety Policy was dated 2002. At least one policy dated from 1995. Many policies were undated, but the webpages had not been updated for more than ten years. Consequently, employees do not have ready access to recent health and safety information.
Documentation of health and safety training
As stated in the Regulations, "the employer shall keep, in paper or computerized form, records of the education provided to each employee, which shall be kept for a period of two years after the employee ceases to be exposed to a hazard."Footnote 6 During the audit period, the health and safety unit did not have a consistent system to monitor and record employee health and safety training. Training records are stored in an employee’s file in PeopleSoft. Health and safety also kept a master training spreadsheet.
We checked the records of a sample of employees and managers/supervisors. Even using both record keeping systems, there was no evidence that the majority of the sample had received all training required by the Canadian Grain Commission’s core learning map. Health and safety staff were confident that employees had completed most of the training courses, and that results were simply not recorded properly. However, there is not enough documentation to prove that employees have completed the courses. It is possible that employees may not have completed certain online courses.
Health and safety provides some required training as classroom courses, but many courses are delivered online. Staff assign online courses to the employee. The employee must prove they have completed the course by sending a screen shot or email back to health and safety. Health and safety does not reconcile training assigned to confirmations received because supervisors are responsible for ensuring their employees have completed the required training. However, as we could not confirm that supervisors received their own required training, they may not be fully aware of this responsibility. Also, health and safety has not always received timely information about when employees were given supervisory responsibility. They have recently initiated new processes with other units in Human Resources to help ensure they are notified of promotions to supervisory positions in a timely manner.
Retraining is offered by a case-by-case basis. Returning employees who have been away from the Canadian Grain Commission for at least two years receive retraining. Grain Research Laboratory employees undergo some refresher training due to specific requirements of the laboratory environment. Otherwise, employees do not receive scheduled refresher health and safety training unless requested by the manager of a particular area. As a result, employees can go years without taking any training related to safety procedures or health considerations. This could lead to under-reporting of incidents or hazards and reduced overall engagement in health and safety activities.
Recommendation 4: policies
We recommend that updated policies be completed, approved, communicated and made available to all employees as soon as possible.
Recommendation 5: training records
We recommend that
- employee records be reconciled to required training and any gaps remediated with additional training as required
- in the future, health and safety follow-up on assigned online training to ensure it is completed within the given timeline; managers and supervisors should be assigned accountability for outstanding training through regular reporting to the executive management committee
- health and safety and the NOSH committee work together to identify where employee training should be refreshed and when, and establish a plan to develop and deliver of refresher training on a cyclical basis
1.4 Control activities
The health and safety unit is the central point that supports the controls in place to ensure that the Canadian Grain Commission remains in compliance with Part II of the Code, the Regulations, and its own policies. To achieve this, we expected health and safety would have a structured approach to planning, monitoring and reporting on its activities.
The director of Human Resources and the manager of health and safety set annual objectives for the unit, and several ongoing internal projects have been established. These goals are not generally shared with Workplace Health and Safety Committees or others, including senior management.
Performance measures for a health and safety function may include measures based on
- financial information (budget, cost, savings, etc.)
- statistics (accident rate, workers compensation costs)
- employee knowledge, perceptions, or satisfaction
Reports are submitted to Employment and Social Development Canada as required, and the manager of health and safety reviews certain metrics internally. However, the health and safety program does not have formal performance measures in place. Consequently, the deputy head, senior management, Workplace Health and Safety Committees, and employees in general do not have a clear picture of the program’s effectiveness.
Creating meaningful performance measures for health and safety activities is difficult because most attributes, such as the number of accidents or effectiveness of a preventative measure, have multiple contributing factors. However, factual information about financials, other measures, and employees can help management and others determine the effectiveness of the program.
Overall costs, cost of specific initiatives, and comparison to budget are typical financial measures for a unit or program. We attempted to review financial measures, but the Human Resources budget is not allocated by individual unit. Instead, the cost of any health and safety programs are included in the general Human Resources budget or the operating budget of the division using the equipment or service. As a result, we were unable to determine, or even estimate, the cost of the health and safety program. Project codes (internal order numbers) are not used to track specific initiatives (such as specialized ergonomic office equipment beyond the standard workstation) so cost tracking and monitoring is unavailable.
The health and safety unit could use consolidated reporting of the number and severity of incidents and accidents could be used to identify risk areas and trends over time. The costs of preventative actions could be compared to these results to indicate if the program is having an effect.
The number of employees who have completed all required training, or who have outstanding training, would provide monitoring and compliance information for senior management. The performance of Workplace Health and Safety Committees, including the number of meetings, workplace inspections, hours of additional training, etc. would also provide useful information for senior management.
These are just examples of measures that can be used to monitor and assess the health and safety program, as well as to guide objectives, goals and initiatives for the next planning cycle. Sharing plans and results with the Workplace Health and Safety Committees could increase engagement and reduce resource requirements, as some tasks may be delegated to committee members. Reporting on specific measures may also help identify areas where individual management teams can be held accountable for ensuring they are carrying out their responsibilities.
Recommendation 6: performance measures
We recommend that the health and safety unit
- accumulate statistics and information about other performance measures, including working with finance to develop coding that would allow them to track costs
- engage in an annual planning exercise to determine strategy and priorities for the upcoming year, and identify or develop key performance indicators
- report key performance indicators to senior management on a regular basis and to the Chief Commissioner at least annually
1.5 Processes to reduce and prevent injury
This criterion was tested and reviewed as part of the evaluation of the hazard prevention program. Refer to Objective 2, below.
Objective 2: To evaluate the effectiveness of the Canadian Grain Commission's hazard prevention program in accordance with section 19.7 of the Canada Occupational Health and Safety Regulations
Workplace Safety & Prevention Services conducted an in-depth evaluation of the Canadian Grain Commission's hazard prevention program. The evaluation included site visits (at headquarters and within each region), interviews, and document review. Workplace Safety & Prevention Services provided a detailed report to the health and safety unit and presented their findings to the executive management and NOSH committees.
Recommendation 7: hazard prevention program
We recommend that management review the Workplace Safety & Prevention Services report, assess the risks of each finding, and establish action plans to address gaps identified in the hazard prevention program. Management should provide periodic updates to the executive management and NOSH committees for monitoring.
Acknowledgements and contacts
We express our appreciation to staff and management of the Human Resources division as well as other interviewees from throughout the Canadian Grain Commission for their assistance during the course of this audit.
This audit has been reviewed with:
Director, Human Resources
Manager, Health and Safety
Audit & Evaluation Services contact:
Chief Audit Executive
Senior Internal Auditor
Appendix A – Summary of recommendations and management action plans
The following is a summary of recommendations contained in this report with management’s action plans to address them.
|Recommendation||Management action plan|
|Recommendation 2: Workplace Health and Safety Committee performance|
|We recommend that the health and safety unit monitor the performance of the Workplace Health and Safety Committees against the requirements of Part II of the Code and report the results to senior management. Non-compliance should be investigated and resolved as soon as possible.||
|Recommendation 4: policies|
|We recommend that updated policies be completed, approved, communicated and made available to all employees as soon as possible.||
|Recommendation 5: training records|
We recommend that:
|Recommendation 7: hazard prevention program|
|We recommend that management review the Workplace Safety & Prevention Services report, assess the risks of each finding, and establish action plans to address gaps identified in the hazard prevention program. Management should provide periodic updates to the executive management and NOSH committees for monitoring.||
|Recommendation 1: risk assessment|
We recommend that:
|Recommendation 6: performance measures|
We recommend that the health and safety unit:
|Recommendation 3: collaboration|
We recommend that the Workplace Health and Safety Committees create a centralized log for tracking and monitoring committee action items. The log would encourage sharing between committees and allow them to identify similar issues.
Appendix B – Audit Criteria
|Audit objective 1: To provide assurance that the health and safety unit efficiently and effectively enables the Canadian Grain Commission to meet its health and safety goals||Audit Criterion 1.1: Roles and responsibilities for the health and safety unit are clearly defined and communicated to ensure their activities are implemented effectively.|
|Audit Criterion 1.2: The health and safety unit collaborates with the NOSH committee, Workplace Health and Safety Committees, and management to establish effective goals and priorities.|
|Audit Criterion 1.3: Occupational health and safety policies, training, awareness programs, and supporting tools are established, delivered, monitored, and updated.|
|Audit Criterion 1.4: Management control activities are in support of the Canada Labour Code – Part II and Canadian Grain Commission’s occupational safety and health policies, guidelines, and processes.|
|Audit Criterion 1.5: Processes are in place to reduce and prevent employee injury and illness in all work locations. This criterion was not tested.|
|Audit objective 2: To evaluate the effectiveness of Canadian Grain Commission’s hazard prevention program in accordance with Section 19.7 of the Canada Occupational Health and Safety Regulations||Audit Criteria for this objective are included in the Workplace Safety & Prevention Services report.|
Appendix C – Impact of Recommendations
The following categories have been applied to each recommendation within this report. Categories are defined as follows:
- will improve management controls or control environment for the overall program/process/area/division/etc.
- may take considerable effort to implement within the operational environment or may involve a significant change
- may have a significant financial impact
- likely results in assumption of a substantial risk if not implemented (ex. decreased efficiency, higher risk of errors, lost cost savings opportunities)
- will improve management controls in that area
- will improve efficiency and/or effectiveness of operations in that area
- is not likely to require a significant effort to implement
- may have some financial impact; could be a less significant item that could accumulate over time to create a larger impact
- promotes a good management practice
- likely improves day-to-day work experience
- likely requires minimal effort to implement
- will have limited financial or operational impact
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