It is the policy of the federal government to ensure all employees are provided a safe and healthy work environment. The Canada Labour Code, Part II (CLC) and its regulations, is key in governing health and safety activities within federal government departments. The purpose of the legislation is to prevent accidents and injury to health arising out of, linked with, or occurring in the course of employment.

The CLC requires that all federal government departments establish health and safety programs to address occupational issues such as accident prevention and investigation, hazards elimination and prevention. The establishment of workplace health and safety committees and the provision of training are also fundamental requirements.

It is the responsibility of every employer to promote a safe and healthy workplace for employees, and to reduce the incidence of occupational injuries and illness.

Objectives and Scope of the Audit

The objective of the audit was to determine the extent to which Fisheries and Oceans Canada (DFO) Occupational Health and Safety Management Control Framework (MCF) supports the creation of working conditions that are favourable to the safety and health of employees and any persons granted access to DFO workplaces.

The audit examined the following elements or lines of enquiry:

The Management Structure (organization structure, leadership, roles, responsibilities and accountabilities);
Policies, Guidelines and Procedures;
Planning, Risk Management and Performance Measurement;
Competencies, Training and Awareness.

Key Findings

Improvements have been made to the departmental OHS Program since 1999.

Comprehensive OHS policies have been developed and consolidated into a departmental Loss Control Manual;
A detailed OHS Accountability Framework has been developed to clarify OHS roles and responsibilities;
A comprehensive OHS Training Program has been developed for DFO managers and staff, including an OHS Awareness Supervisors Guide and an OHS Awareness Handbook for Employees; and
The members of departmental OHS Site Committees are dedicated and diligent in addressing safety issues that come before them.

The Department requires a more coordinated and systematic approach to OHS

The Audit Team found significant variations in safe operating practices and the implementation of OHS policy within regions and between regions. Best OHS practices are often not shared, sometimes even within regions;
A more systematic approach, as embodied in a Safety Management System (SMS) is required to successfully implement and maintain an effective OHS Program.
A SMS is an integrated and systematic approach to the implementation of a safety program which identifies and prioritizes safety risks and implements procedures and controls to prevent or minimize these risks. These systems are characterized by clearly defined safety procedures, safety training programs, supporting documentation, regular safety monitoring programs and active management leadership and support.
In 1999, DFO purchased the organization-wide rights to a Safety Management System developed by Det Norske Veritas (DNV), an internationally recognized authority on OHS. The purchase price for these rights was $1.2 million. This system is based on the International Safety Rating System (ISRS). The DNV package has been used to facilitate the development of the DFO OHS training modules and provide criteria frameworks as guidance for OHS audits. However, no coordinated departmental effort has been made to use the package to facilitate the implementation of a comprehensive OHS SMS in the Department.
The CCG Fleet organization is the only departmental group which has a nationally implemented SMS, the International Safety Management (ISM) System.
The CCG plans to implement a SMS across the remainder of its organization and the Pacific Region plans to implement it on a region-wide basis..
There are currently no plans in DFO to coordinate the implementation of a SMS in the non-CCG components of DFO or in Regions other than the Pacific.

Departmental functional authorities for the OHS Program lack support.

Inadequate regular and direct communication between the Director of Safety and Security and the Deputy Minister increases the potential that important OHS issues and planned strategies are not adequately conveyed in a timely fashion to senior departmental management.
Weak support for departmental OHS functional authority has resulted in the lack of timely responses to instances of non-compliance with the Canada Labour Code. For example, we observed a lack of compliance with OHS Site Committee meeting frequency and site inspection requirements. In Addition, we noted that OHS training which is mandatory under the Canada Labour Code for managers and supervisors was not made mandatory department-wide.
There is no formally accepted departmental OHS system audit program. This is in contravention of the Canada Labour Code as well as the departmental Loss Control Manual.
Many senior departmental managers are not visible in demonstrating their support for the OHS function through such activities as participation in OHS site inspections. This participation is required under departmental OHS policy.
Senior departmental management has tended to be more reactive to OHS issues rather than strategically proactive.
Lack of clarity surrounding the role of the departmental Champions for Workplace Health and Well-being as it pertains to support for the OHS function.

Absence of a risk-based approach to OHS planning

The OHS training strategy is a key component of the OHS Plan, it focuses on manager and supervisor training but does not in most regions adequately address other high risk areas such as staff training and orientation training.
The current planning processes supporting the Headquarters and regional OHS function are not sufficiently risk-based, nor sufficiently comprehensive to be considered viable planning instruments.

Accountability for Resources

Additional FTE Cap approved funding was provided to each region in the 2004/05 DM Allocation. These resources were approved to staff new high priority OHS Advisor positions.
Significant delays in approval for staffing meant that the regions could not begin the staffing process until well into the third quarter of FY 2004/05.
Regions did endeavour to reallocate the lapsing incremental fiscal year 2004/05 salary dollars to other OHS, Security, Emergency Preparedness or Business Continuity Planning initiatives. Nevertheless, this reallocation or resources was not able to address significant, high priority OHS regional issues related to the staffing of additional OHS Advisors, as was originally anticipated in the Business Case used to secure DMC approval for additional resources.
The Audit found that the controls to ensure accountability for the expenditure of DMC approved OHS incremental resourcing are ineffective.

Key Recommendations

Implementation of Safety Management Systems (SMSs) in all DFO organizations;
Greater use of Accountability Accords and Service Level Agreements to ensure greater accountability for adherence to key OHS policies, achievement of OHS initiatives and resources allocated to the OHS function;
Increased communication with senior management pertaining to OHS;
Increased visible support by senior management to OHS;
Implementation of a comprehensive, risk-based OHS monitoring program; and
Greater application of risk-based methodologies to business and operational planning.

A summary of all the recommendations contained in this audit report can be found in Appendix A.

2.0 Introduction

2.1 Background

It is the responsibility of every employer to promote a safe and healthy workplace for employees, and to reduce the incidence of occupational injuries and illness.

Since 1999, Fisheries and Oceans Canada (DFO) management has been working towards the establishment of a strengthened health and safety program for the Department to ensure that the provisions of the CLC are being followed. A set of action items to improve the internal responsibility system were adopted by DFO senior management at that time and are at varying stages of implementation. In addition, recent DM allocations to the DFO Headquarters and regions included additional resources to be applied to the strengthening of the Occupational Health and Safety (OHS) function.

The DFO OHS function has not been the subject of a formal departmental internal audit since 1995. Given the importance of this function to the Department and its employees, an audit of the Management Control Framework for OHS was included in the 2004/05 DFO audit plan, approved by the Departmental Audit and Evaluation Committee (DAEC).

2.2 Objectives and Scope

The objective of the audit was to determine the extent to which the DFO Occupational Health and Safety Management Control Framework (MCF) supports the creation of working conditions that are favourable to the safety and health of employees and any persons granted access to DFO workplaces.

A Management Control Framework is an integrated collection of management structures, policies, practices, controls, systems, and functions designed to ensure the cost-effective achievement of operational and program objectives. The MCF supporting OHS in the Department includes:

The Management Structure (organization structure, leadership, roles, responsibilities and accountabilities);
Policies, Guidelines and Procedures;
Planning, Risk Management and Performance Measurement;
Competencies, Training and Awareness.

The focus of this audit is on the OHS Management Control Framework (MCF). Specific site safety practices were not examined with the intent of providing assurance of adherence to safe working conditions and practices. The audit did, however, review selected site safety conditions and practices to provide evidence of the effectiveness of the implementation of the departmental OHS MCF.

2.3 Methodology

The Audit Team interviewed and gathered information from all Regions and in Headquarters. The main focus of these interviews was to determine how interviewees understood and applied OHS practices and standards in their own environment. In addition, visual observations, and testing were done on OHS policies, practices at selected sites to obtain evidence of the overall effectiveness of the management control framework.

In addition, the Audit Team undertook a high level review of the implementation of the key elements of the MCF in other selected Federal Government departments for comparative purposes.

The lines of enquiry and associated criteria presented below provide details of the specific areas in which the Audit Team focused its interviews and data gathering efforts.

2.4 Lines of Enquiry and audit criteria

Overview

The following is an overview of the lines of enquiry and audit criteria that were pursued by the Audit Team to assess the adequacy of the OHS Management Control Framework. Lines of enquiry are the broad subject headings describing areas determined, during the Planning Phase, to be the most productive for audit. Each line of enquiry is accompanied by audit criteria, which were used to assess the adequacy of the control framework. These audit criteria describe an expected optimum state found in organizations with an effective OHS Management

Control Framework.

1. Line of Enquiry - OHS Management Structure

Audit Criteria

Departmental senior management demonstrates leadership and involvement in promoting OHS.
OHS related organizational and committee structures as well as associated reporting relationships are established and communicated and support program objectives and the coordination of decisions and actions.
Roles and responsibilities are clearly defined, communicated and understood.
Authorities and accountabilities are appropriately aligned to roles and responsibilities, communicated and understood.
Performance agreements and Accountability Accords incorporate managers/supervisors duties and responsibilities as described in departmental OHS policies and the Canada Labour Code Part II.

2. Line of Enquiry – Policies, Guidelines and Procedures

Audit Criteria

Comprehensive OHS policies have been developed and consolidated into a departmental OHS Manual/Guide. These policies and any associated guidelines or procedures are communicated and understood to ensure achievement of OHS objectives.
A documented communication strategy is in place to ensure that managers and employees are kept informed of requirements, issues, and implications of the Canada Labour Code Part II, on a regular and ongoing basis.
Formal mechanisms are in place to monitor activities in support of compliance with departmental OHS policies. Analysis of information gathered identifies issues as well as opportunities and best practices.

3. Line of Enquiry – Planning, Risk Management and Performance Measurement

Audit Criteria

Risk-based business plans have been developed, both at the national and regional level to provide guidance and direction in relation to the implementation of the OHS Program.
Standard processes and systems exist to effectively identify funding requirements, prepare budgets and allocate resources in support of approved plans. Planned activities are prioritized according to risk to ensure available funds are applied to the highest priority activities.
Appropriate mechanisms are in place to ensure risks are identified, assessed, managed, mitigated and communicated to the proper level of authority in a timely manner. Tolerable levels of risk exposures have been defined and approved.
Performance measures and indicators pertaining to OHS have been established, agreed upon, communicated and monitored. The performance measurement system is sound and ensures that pertinent related information is gathered at all levels of the organization.

4. Line of Enquiry – OHS Competencies, Training and Awareness

Audit Criteria

Core competency requirements, knowledge and skills, are defined in relation to roles and responsibilities, authorities and accountabilities, and are aligned with program objectives.
New employees are given an OHS briefing or orientation to inform them of the OHS policies and supporting procedures as well as any specific OHS requirements of their jobs.
Ongoing OHS training and awareness programs are in place to ensure departmental management and staff understand their continuing OHS responsibilities.
Departmental management and staff who perform full or part-time OHS duties are provided the opportunity to receive OHS related training to keep them current with evolving OHS practices and procedures.
A program is in place to measure the effectiveness of the OHS education and awareness program and strategy.

3.0 Observations and Recommendations

3.1 OHS Management Structure

3.1.1 Overview

The management structure can be defined as the departmental organization structure for OHS, the associated roles and responsibilities of the various offices, and the overall organizational capacity to support an effective OHS Program.

Within DFO the Deputy Minister (DM) is responsible for implementing the requirements of the Canada Labour Code, Part II (CLC), and its regulations and establishing and maintaining an effective OHS Program consistent with Treasury Board policies, standards and procedures.

The Assistant Deputy Minister Human Resources and Corporate Services (ADM HR&CS) is responsible for supporting the development, implementation and monitoring of the departmental OHS program. He must ensure that managers and employees are aware of and comply with the legal requirements of the CLC, the OHS Policy for the Public Service and the departmental OHS Policy.

The Director General of Real Property, Safety and Security and specifically the Director of Safety and Security are responsible for the provision of functional guidance to the DM and ADM HR&CS on the discharge of their OHS responsibilities.

The Regional Managers of Safety and Security act at the regional level to provide OHS functional guidance to regional managers.

All managers and supervisors, at any organizational level of the Department are responsible for ensuring compliance with the CLC and implementation of the OHS Program within their area of responsibility.

The CCG Fleet has adopted an OHS policy framework that is unique to the international marine community. This policy framework is part of an internationally recognized marine safety program, the Management Code for the safe operation of ships and pollution prevention (ISM code). Elements of the CLC and Treasury Board OHS requirements still apply to the Fleet for safety related areas not covered under the ISM. The CCG Commissioner is designated as the Authorized Representative (Managing Owner) of the DFO CCG Fleet and is accountable for the implementation of the IMS.

OHS committees at the national, regional and site levels of DFO participate with management in developing and monitoring the health and safety program established by the Department.

3.1.2 Organizational Structure

Findings

In fiscal Year 2002/03, an additional $2.1 million was allocated to the Headquarters Safety and Security organization and $67,000 to each region to improve the coordination and implementation of the safety and security functions in DFO. In 2004/05, all regions were allocated $250,000 to $350,000 per region from the DM allocation budget. Part of the business case supporting this additional funding made reference to a more generic organizational structure and related job descriptions to support regional OHS and Security related functions.
The allocation to the regions was made entirely in Operations and Maintenance (O&M) dollars even though the Business Case on which the allocation was based specified the requirement for additional Full Time Equivalent (FTE) and associated salary dollars. As a result, for 2004/05, the ADM HR&CS absorbed the additional funding requirements resulting from the conversion factor of O&M to salary dollars. The regions have been informed that they will be responsible for absorbing the salary conversion factor for 2005/06 and ongoing. This could result in some regions being unable to fully staff required OHS Advisor Positions as was originally intended.
A generic regional OHS organizational structure has been developed and is being implemented in each region with temporary transitional variations agreed to for some regions. This structure places the OHS and Security units in the same organizational grouping as Real Property and Environment thereby being consistent with the Headquarters structure. This organizational consistency will facilitate communication between Headquarters and the Regions as well as facilitate Headquarters functional monitoring of resource utilization in the specific functional areas.
Generic job descriptions, for positions in regional OHS units have been developed and are in final classification stage.
There were significant delays in staffing new Regional OHS Advisor positions, approved and funded in the 2004/05 DM Allocation to the regions. These staffing delays can be attributed to delays in the development and classification of generic OHS Advisor job descriptions as well as to the decision by the ADM HR&CS to require regions to approve the Real Property, Safety and Security and Environment common generic organization model for regional application prior to proceeding with any incremental staffing of OHS Advisors. Since the generic national job descriptions were not completed in 2004, regions which were committed to implementing the generic national organization structure were allowed to begin the process to staff needed OHS Advisors by using classified OHS Advisor Positions cloned from existing regional positions.

Conclusion

The current initiative to create a more regionally consistent OHS related organizational structure will, once implemented, facilitate the implementation of a more effective and accountable OHS program in DFO. However, the resulting inability of the regions to staff required OHS Advisor positions that were approved and funded by DMC, seriously limited the capability of regions to address significant existing OHS deficiencies. This was particularly true for the smaller regions, Gulf, Quebec, Central and Arctic, and Newfoundland.

Regions did endeavour to re-allocate lapsing incremental Salary resources to other OHS, Security, Emergency Preparedness or Business Continuity Planning initiatives in 2004/05. Nevertheless, this reallocation of resources was not able to focus on significant, high priority OHS regional issues that were to be addressed by the staffing of additional OHS Advisors, as was originally anticipated in the Business Case used to secure DMC approval for additional resources. The current environment of funding scarcity within DFO makes it critical that resources are efficiently and effectively used to further departmental objectives.

The issue of the effective utilization of incremental funding granted to the regions to address significant OHS issues is referenced in more detail below – Accountability for Resources.

3.1.3 Accountability for OHS Related Resource Allocations

As stated above delays in approval for staffing new OHS Advisors resulted in the inability of regions to deliver the OHS program as articulated in Business Case presented to DMC.
There are currently few effective controls on how new incremental funding is spent, such as the additional regional OHS funding granted in 2004-05 DM Allocation. The Service Level Agreements (SLAs) between the ADM HR&CS and the RDGs do reference the disposition of the 2004/05 incremental funding for regional safety and Security as follows:

"ADM HR&CS and RDGs will work together to ensure that the new resources provided by DMC for safety and security as described in the service standards are used effectively. RDGs agree to maintain all existing resources devoted to these functions and the delivery of services."

This statement in the SLA does provide some indication that there is a commitment to ensure the 2004/05 incremental regional Safety and Security funding is effectively utilized in these functional areas. The Headquarters Functional Authority did request that the regions identify how the new incremental O&M and FTE resources were allocated to the four functions of Safety and Security (that is OHS, Security, Business Continuity Planning and Emergency Preparedness). However, no attempt was made to monitor the actual utilization of the new incremental resources allocated in fiscal year 2004/05 to regional Safety and Security functions. Such tracking is made somewhat difficult because the current regional variations of organizational structure encompassing the OHS function. The content of this particular SLA element does not appear in the Accountability Accords of the ADM HR&CS or any of the RDGs, it therefore would not be reported via the departmental Accountability Accord process.
Regions reported redirecting the funds planned for additional OHS Advisors to other OHS or Security related activities. It was not within the scope of this audit to verify whether the incremental resources received in FY 2004/05 for Safety and Security were actually all spent within the Safety and Security functions.

Conclusion

The allocation of new incremental resources to regional Security and OHS functions was approved as part of the A-Base for each region. The controls to ensure accountability for the expenditure of this new, DMC approved OHS incremental resourcing are ineffective. Controls are required to ensure visibility and accountability for any reallocations that do occur.
Controls could take the form of monitoring by the OHS Headquarters functional authority to ensure any reallocations are identified and accounted for. They could also entail the holdback of new incremental resources until there is adequate assurance that organizations have in place the capacity to utilize the resources in a manner consistent with the proposal under which they were approved.

3.1.4 OHS Committees

Findings

The Canada Labour Code Part II, supplemented by Treasury Board directives and the DFO Loss Control Manual (LCM) sets out the requirement to establish OHS Committees at all departmental sites where 20 or more staff are employed. At sites with fewer than 20 employees, an OHS representative is chosen by site employees and formally appointed by management to act as the focal point for addressing and reporting OHS issues to management. Site OHS committees, are required to meet at least nine times per year.
The CLC also sets out the requirement to establish a National Policy Health and Safety Committee. In addition, the LCM stipulates that a Regional OHS Committee be established in each region. The regional and the national committees are required to meet four times per year
These committees under the CLC and LCM are required to be comprised of at least an equal number of labour representatives to those from management. It is acceptable to have more representatives from labour than management. The overall purpose of these committees is to participate with management in the development and monitoring of the health and safety program established by the Department, ensuring it complies with the CLC.
A review of the proceedings and minutes of a sample of OHS Site Committee meetings, as well as Regional and National level OHS committees, found that committees are diligent in addressing OHS related issues that come before them. OHS Site Committee members also conduct workplace safety inspections as dictated by the CLC.
The OHS Committees are good examples of DFO management, employees and unions working together to promote safer work environments for departmental employees and anyone granted access to DFO facilities and properties. Those Committee members interviewed by the Audit Team demonstrated a high level of dedication and commitment to ensuring safe departmental working conditions even though memberships on these committees is outside normal work requirements and certainly for employee members, totally voluntary.
There are 73 OHS site committees in the Department. According to the CLC these committees are required by law to meet at least nine times per year. In 2003 only 55% of DFOs OHS site committees complied with this meeting frequency requirement. This percentage ranged from a high of 75% in the Maritimes Region to a low of 13% in the Quebec Region. Some regions have demonstrated improvement during 2004, however, the adherence to CLC minimum meeting frequency requirements in DFO is still below 40% department-wide.

The requirement for site committees to meet at least nine times per year may be seen as arbitrary by many, however, it is based on the principle that the safety of an organization’s employees dictates that workplace safety issues be subject to frequent examination. The Newfoundland, Maritimes and Quebec Regions monitor the frequency of OHS Site Committee meetings quarterly. The remaining Regions monitor the frequency of these meetings annually. The Headquarters OHS Unit requires only an annual report of site OHS Committee meetings. These regional reports are tabled at the National Policy Health and Safety Committee. The annual monitoring of OHS Site Committee meetings does not identify non compliant committees during the year therefore meeting frequency issues are not recognized until year end. The Audit Team found that the lack of compliance with CLC OHS Site Committee meeting frequency requirements in both 2003 and 2004 is largely the result of a lack of timely monitoring and subsequent management intervention.
As stated, regional OHS Committees are required to meet four times per year. The committees in Newfoundland, Gulf and Quebec Regions did not meet four times in calendar year 2004. The PSAC strike in 2004 and related lack of union participation in departmental meetings was cited as one reason regional OHS Committees did not meet according to the frequency requirement. However, under provisions of the DFO LCM these regional committees are required to meet regardless of any lack of participation from the employee/union side.
A review of the minutes of a sample of OHS Committees at all levels of the DFO organization found that the committees tend to be reactive to specific OHS related issues. Very little proactive OHS initiatives were observed in the kinds of initiatives, activities and issues under consideration by departmental OHS committees. The involvement of the national and regional OHS committees in promoting and monitoring regional OHS training is one of the few examples of significant focus on taking strategic, planned action to further the OHS agenda in the Department.
Since OHS Committee members participate in committees in addition to their regular work-related duties, it is not surprising that OHS Committees, at all levels, are not the source of significant proactive strategic OHS initiatives. These committees rely heavily on advice and guidance from the regional and Headquarters OHS organizations. Their role is to participate with departmental management in the promotion of safe work environments in DFO. For the most part, these committees look to the OHS Advisors to provide strategic direction for their consideration.

Conclusion

OHS Committees in DFO and their dedicated members provide a positive contribution to improving workplace safety in the Department. The additional A-Base resources provided to the regional OHS function in the 2004/05 DM Allocation will ultimately allow the staffing of additional OHS Advisors. This increased capacity should enable regional OHS units to provide more strategic, proactive support to Regional OHS Committees.
At the regional and site level many committees are not meeting according to the frequency requirements as stipulated in the CLC and the DFO LCM. This situation, if allowed to persist, has the potential to undermine and diminish the significant contribution DFO OHS Committees make to safety in the Department.

3.1.5 OHS Roles, Responsibilities and Accountabilities

Findings

The accountability framework associated with OHS is very clear as described in the CLC and the departmental Loss Control Manual (LCM). The LCM in particular, identifies the responsibilities and accountabilities associated with the OHS function. It details the roles, responsibilities and accountabilities of the Deputy Minister, ADM HR&CS, Director of Real Property, Safety and Security, Director of Safety and Security, Headquarters OHS Chief, Regional Directors General, Regional Director Real Property, Safety and Security, Regional Manager Safety and Security, Regional OHS Advisors as well as defines the role of the departmental OHS Committees. In addition the LCM describes the accountabilities of all departmental managers, supervisors and employees.
The Headquarters and regional OHS organizations have also developed an OHS Accountability Framework that further clarifies and distinguishes between the accountabilities of the Headquarters OHS organization, the Regional OHS organization and management in advancing the departmental OHS Program.
The Audit Team found that individual managers have a growing awareness of the responsibilities and accountabilities they have for the safety of employees working under their direct line management authority. In several instances noted by the Audit Team, this awareness has resulted in safety practices being implemented in a line manager’s organization.
The Audit Team observed significant variations in safe operating practices within regions and between regions. Best OHS practices are often not shared, sometimes even within regions. The CLC stipulates that accountability for the safety of employees is not restricted to managers with direct line supervision. The lack of a more coordinated approach to the implementation of safe workplace procedures and conditions demonstrates a lack of understanding and awareness, amongst many of the more senior ranks of the organization pertaining to their obligations and liabilities for the safety of all those employees over which they have control or influence. This includes RDGs as well as Regional Directors who have functional authority over regional operations. It also includes Headquarters Sector ADMs who have functional authority influence over the operating practices and procedures used in regions.

There are some examples in DFO where there is a more coordinated, systematic approach to OHS implementation, notably the Fleet Safety Management System in the CCG Fleet.

The Audit work revealed only a few instances where Executive level Accountability Accords meaningfully referenced any commitments to the completion of OHS initiatives. Usually an OHS reference was seen only in Accountability Accords of Executives that had direct line authority over either Headquarters or regional OHS units. The DM’s Accountability Accord makes no Key Commitment references to OHS initiatives.

Conclusion

The CLC, the LCM and the OHS Accountability Framework, provide clear statements pertaining to the obligations of managers to ensure that the work environment over which they have control or influence is maintained in a healthy and safe condition. For senior departmental Headquarters and regional management this accountability has not, for the most part, been interpreted as a requirement to take proactive steps to ensure that there is a co-ordinated approach to the creation of an OHS program within the overall organization over which they have control or influence.
Currently the CCG Fleet is the only departmental organization that has implemented a comprehensive OHS Safety Management System (SMS) to ensure the implementation of safe working practices nationally. However, senior management in the Pacific Region have decided to implement a SMS to cover all DFO employees who come under the authority of the RDG. The CCG Management Board has made the decision to nationally implement a version of the SMS, developed in the Pacific Region, in all shore-based organizations in the CCG. The importance of a more systematic approach to the implementation of the LCM in DFO is addressed in detail in Section 3.2.4 below -Requirement for a Safety Management System (SMS).

3.1.6 OHS Functional Authority

Findings

The Functional Authority Management model is a key element of the overall governance model of the Department. In DFO this model consists of the establishment of Headquarters functional authorities for the various major departmental functions, for example, Human Resources, Finance, Conservation and Protection, Security and OHS. These authorities are accountable for the provision of advice, guidance, policy direction and monitoring in their functional area. Headquarters functional authorities are supported by regional functional authorities who support and act on behalf of the Headquarters functional authorities.

In effect, functional authorities in the DFO Governance Model act on behalf of the DM, through the associated ADMs to ensure the appropriate direction and coordination occur within the Department for a particular functional area.
The DM looks to the Headquarters OHS Unit, through the ADM of HR&CS to act on his behalf to ensure an effective and coordinated OHS Program is implemented throughout DFO. This oversight functional authority role extends to the CCG Fleet even though the Fleet has implemented its own SMS which meets the requirements of the international marine community. The Headquarters and regional OHS Advisors do provide OHS advice to the Fleet in areas not covered by the Fleet Safety Management System.
The Audit Team found that in Headquarters and some regions, OHS functional authority staff expressed significant frustration pertaining to the degree to which they had influence over departmental management related to the implementation of OHS policy in DFO. Several instances were noted that demonstrate the weakness of the functional influence of the departmental OHS functional authority. For example, Headquarters OHS functional authorities referenced the difficulty they have experienced in obtaining the full cooperation of regional operational managers in carrying out OHS program audits. These audits are an important component of effective OHS functional monitoring.

Another example is the inability of the Headquarters OHS organization to have attendance at the OHS Module 1, (Managers and Supervisors OHS Introductory course) declared mandatory by DMC. Some Regional Safety and Security Managers were able to win support from their regional senior management to make attendance mandatory in their regions. The CLC clearly states courses of this nature are mandatory and should not be promoted as simply a training opportunity.

There has been a recent example when the DM has been asked to intervene and provide specific direction to RDGs to adhere to departmental OHS Policy when the departmental OHS functional authority has not been successful. In this case, the DM signed a memorandum to all RDGs directing them to ensure that the Regional OHS Committees meet at least four times per year as stipulated in the LCM. Previous to this memo several ROHS Committees had not been meeting at the frequency stipulated in the LCM.

Conclusion

Weakness in functional authority can be found in many functional areas of the Department. Increased senior management leadership and involvement in OHS; improved communications between Headquarters and regional OHS Units; and a more systematic approach to the implementation of OHS initiatives would contribute to a strengthened OHS functional authority. There is a requirement, however, for the DM to monitor the effectiveness of the functional authority supporting the OHS function and intervene when appropriate to lend the authority of the DM’s office in support of the DFO OHS functional authority.

3.1.7 Communication with Senior Management

Findings

Given the significance of the OHS function to the Department and its staff, it is important that the DFO OHS Functional Authority, the Director of Safety and Security has direct access to the Deputy Minister (DM). In the regional context, it is equally important that the Regional OHS Functional Authority, the Manager of Safety and Security, has direct access to the Regional Director General. A dotted line reporting relationship exists between the Director of the Safety and Security Branch and the DM pertaining to Security matters. An audit of the Security function in 2003/04 recommended a similar formal dotted line reporting relationship be established for Security between the Regional Manager of Safety and Security and the RDG.

Such a formal dotted line reporting relationships does not exist pertaining to OHS at either the Headquarters or regional levels. In addition, there have been relatively few instances where OHS related issues and concerns have been brought to the direct attention of the DM or DMC. Staff of the OHS Headquarters Unit reported having difficulty in getting OHS items on the DMC agenda.

The International Safety Management (ISM) System established in the CCG Fleet operations recognizes the necessity for direct and immediate access by the National Fleet Safety Coordinator to the Commissioner of the CCG. This requirement is established as a formal dotted line relationship and its practical application is subject to regular external audits of the CCG Fleet as part of the ISM.

Conclusion

Without formal recognition of the requirement for the Headquarters Director of Safety and Security and the Regional Managers responsible for OHS to have direct and immediate access to the DM and RDG respectively, there is a greater risk that communication pertaining to OHS issues to senior management will be ineffective. In addition, regular OHS significant issue briefings to the DM, Commissioner CCG and RDGs would also help ensure senior departmental management is kept fully aware of current OHS issues and initiatives. This would not only increase senior management awareness but also be a significant manifestation of "due diligence".

3.1.8 Leadership

Findings

An essential component in the creation of a safety culture in an organization is the demonstrated commitment of senior management to OHS initiatives. This involvement and commitment can take many forms. We found that all senior managers interviewed both in Headquarters and in the regions, are very supportive of OHS principles and practices. When safety issues are brought to their attention, senior departmental managers were found to react positively and quickly in addressing issues brought to their attention.
Relatively few instances, however, were identified where senior departmental managers were engaged proactively in demonstrating their commitment to OHS. Chapter 1 of the departmental LCM specifically states that ADMs should ensure that senior managers in their organization participate in at least one OHS inspection per year. The LCM also states that RDGs should participate in at least one OHS meeting annually as well as one OHS site inspection annually. There were some examples noted, especially at the regional level, where departmental directors participated in site and regional OHS Committee meetings. However, there were relatively few examples noted where management at this level and above participated in site safety inspections.
Another way that senior departmental managers could visibly demonstrate OHS leadership would be to attend the Module 1 Introduction to OHS Roles and Responsibilities of Managers and Supervisors. In the Newfoundland, Maritimes and Quebec Regions almost all members of the Regional Management Committees have received this training. In the remaining regions, including DFO Headquarters, the number of senior managers who have attended the Module 1 course is less than 40%.
Leadership for specific significant functions within the Department is often promoted by the designation of departmental champions. For example, there are champions for Employment Equity, Harassment Free Workplace and Official Languages. There are also champions for Recognition and Workplace Well-being. It is not clear whether Workplace Well-being was originally intended to include OHS, although it would be difficult to see how it could be rationally addressed without including OHS.

The champions for Recognition and Workplace Well-being are the RDG Pacific and the Deputy Commissioner CCG. Unfortunately, neither champion has been informed as to what this role entails. The Deputy Commissioner is the Co-Chair of the National Policy Health and Safety Committee and as such plays a prominent leadership role in the promotion of OHS in DFO. This audit could find no evidence of formal Terms of Reference, operating guidelines or commitments of accountability for those senior managers designated as departmental Champions for Recognition and Workplace Well-being.

Conclusion

The few examples of senior management participation in site safety inspections were reported to the Audit Team as having a positive impact on departmental employees. This involvement visibly demonstrates a high level of senior level commitment to OHS. The demonstration of departmental commitment to OHS would be even greater if more senior managers at all levels in the Department participated.

3.1.9 Recommendations – OHS Management Structure

Recommendation 1

The Assistant Deputy Minister of Human Resources and Corporate Services should develop processes to improve the controls associated with the expenditure of new incremental resources allocated for specific functions.

Recommendation 2

The Deputy Minister should monitor, through the Accountability Accords with Assistant Deputy Ministers, the Commissioner CCG and Regional Directors General, the adherence to key departmental Occupational Health and Safety policies and initiatives, with initial emphasis on the meeting frequency requirements for Regional and Site Occupational Health and Safety Committees.

Recommendation 3

The Deputy Minister should ensure that significant Occupational Health and Safety issues and initiatives are included quarterly on the agenda of the Departmental Management Committee.

Recommendation 4

The Deputy Minister should ensure that OHS related communication is formally enhanced between:

- The Director Safety and Security and the Deputy Minister at the Headquarters level; and

- Managers of Safety and Security, Regional Director Generals and Assistant Commissioners CCG at the regional level.

This should be accomplished by:

Including in the Job Description of the Director of Safety and Security, a "dotted line" reporting relationship, pertaining to the OHS function, between the Director and the Deputy Minister.
Including in the Job Description of Regional Managers Safety and Security a "dotted line" reporting relationship, pertaining to the OHS function, between the Regional Manager Safety and Security position and the Regional Director General.
Instituting quarterly OHS key issue briefings between the Director of Safety and Security and the Deputy Minister, and the Regional Managers of Safety and Security and their respective Regional Directors General and Assistant Commissioners CCG.

Recommendation 5

The Deputy Minister should ensure that senior departmental managers proactively demonstrate their leadership and support for the departmental Occupational Health and Safety Program including annual participation in at least one Site Safety Inspection as directed by the departmental Loss Control Manual.

Recommendation 6

The Deputy Minister should ensure that guidelines and Terms of Reference are developed for the departmental champions for Workplace Wellness and Safety and that annual performance expectations for the role of champion be included in the Accountability Accords for the champions

3.2 Policies, Guidelines, Processes and Systems

3.2.1 Departmental OHS Policies

Findings

The Headquarters OHS Unit has developed a comprehensive OHS Policy Manual/Loss Control Manual (LCM) which clearly identifies what should be done to create a safe working environment as well as who is responsible and accountable. The LCM requires minor updating as it currently does not reflect the organizational reporting relationship changes associated with the creation of the Canadian Coast Guard as a Special Operating Agency.
To complement the LCM, the departmental OHS functional authority has created an OHS Awareness Handbook for Employees and an OHS Awareness Supervisors Guide.
The LCM, although it is the comprehensive statement of OHS policy, is not well known within DFO. Some senior departmental managers interviewed during the audit were not aware of its existence.
Other specialized departmental policies and guidelines are in place to address the unique OHS requirements that exist in an operational department such as DFO. For example, the Science Sector has developed a national Laboratory Safety Manual which provides direction and guidance pertaining to safe working practices in science laboratories. The Conservation and Protection organization also has very specific policies, mandatory training and certification requirements relating to the use of firearms and use of force. The CCG Fleet, in addition to its comprehensive Fleet Safety Management System, has a Fleet Safety Manual which documents established safe operating procedures and documentation requirements covering CCG Fleet operations.
An OHS Web Site has been established in Headquarters which provides electronic access to departmental policy manuals and documents as well as CLC legislation, Treasury Board OHS directives and OHS related information from other government and private sector organizations. The site is well laid out and allows ready access to the majority of DFO’s OHS related policy manuals and guides.
Information pertaining to revisions to OHS departmental OHS policy or changes to the CLC are sent by the Headquarters OHS Unit to the Regional Managers of Safety and Security as appropriate. The information is then disseminated to regional managers.

Conclusion

Despite the completeness and accessibility of departmental OHS policy documents and manuals, the majority of employees interviewed as well as many managers are not aware of these documents. This situation is improving as an increasing number of DFO staff attend OHS training sessions which are being delivered throughout fiscal years 2004/05 and 2005/06.
Documented policies are most often adhered to when they are part of a system or process with specific requirements and accountabilities to apply the policy directions contained in policy manuals. Policy documents, like the LCM focus on what is required and who is responsible and accountable. But without a system in place to support OHS policy implementation, consistent organization-wide adherence to policy is difficult to assess.

3.2.2 OHS Systems

PeopleSoft

To meet the requirements of Part II of the CLC, DFO management must be able to monitor that its OHS programs are operating effectively. The requirement to monitor the OHS program is also outlined in DFO’s OHS Loss Control Manual, Chapter 2, Program Monitoring. The department needs an efficient user friendly OHS information management and reporting system that is consistent across, and used in all regions. A Management Information System for OHS is a necessity in order to be able to provide a wide range of statistical reports for decision making and monitoring purposes.

At present, the departmental PeopleSoft program does include an OHS Module that allows users to track incidents and injuries occurring in the workplace for employees and non-employees. However, the system does not contain modules for other relevant information gathering such as meetings, inspections.

The PeopleSoft OHS Module for tracking accident and safety related incidents does not have a reporting capability that allows each of the seven regions to produce its own region-specific statistics, nor for the national office to produce both region and national statistics. Consequently, Regional OHS offices also enter the data into other systems using applications such as Excel and Microsoft Access that allow them to produce statistical tables and graphs. This double-entry of data is time-consuming and expensive.

Local regional OHS systems are also used to track other OHS related activities, such as OHS Committee meeting frequency and site inspections.

Regional OHS offices and National Headquarters recognize the deficiency in the system. Funds had been allocated within a Strategic Investment Fund last fiscal year to:

develop a PeopleSoft reporting capability which would allow each region to produce statistical reports relevant to its needs, and;
update the PeopleSoft OHS module user guide to reflect the latest features of the currently installed PeopleSoft Version 8 of the OHS module

Consultants were hired in January 2005 to develop the reporting capability and to update the user guide. Due to unforeseen circumstances the contractor could not complete the task of developing a PeopleSoft reporting capability; however the guide was completed and distributed to all regions in the spring of 2005.

Conclusion

An essential element of an effective OHS program is the capacity to efficiently track and report on key OHS related activities. The current departmental PeopleSoft OHS Module does not meet this requirement resulting in significant duplication of effort as regions create their own local OHS systems.

3.2.3 Monitoring the Implementation of OHS Policies and Program

Overview

Equally important to the establishment of comprehensive OHS policies is the establishment of a program to monitor compliance to these policies. The following describes the key monitoring initiatives in DFO and the associated audit findings.

Findings

1. Monitoring By the National Policy Health and Safety Committee/Regional OHS Committees

One of the important functions of the National Policy Health and Safety Committee and the Regional OHS Committees is to monitor adherence to selected LCM frequency requirements for OHS related meetings and activities. Some regional OHS Committees monitor on a quarterly basis, the frequency of regional OHS Site Committee meetings to ensure these committees meet at least nine times per year as per the CLC. All regional OHS Committees also monitor at each meeting the progress towards training all managers and supervisors in Module 1 – Introduction to OHS Roles and Responsibilities for Managers and Supervisors. The Headquarters and Regional OHS organizations are also beginning to develop strategies to allow these regional committees to monitor the requirement for all departmental sites to be safety inspected according to the Canadian Labor Code, Part II requirement. The National Policy Health and Safety Committee monitor all of the above and in addition annually monitors adherence to the LCM defined requirement for Regional OHS Committees to meet at least four times per year.
This monitoring activity at the regional and national levels has not, however, led to decisive action on the part of departmental senior management to address identified deficiencies. As stated in Section 3.1.4 a high percentage of Regional OHS Site Committees as well as regional OHS Committees have not met the required meeting frequency requirements for the past two years. Part of the explanation for this inaction can be attributed to the fact that many managers in the Department are not fully aware of the importance of adhering to these meeting frequency requirements, which are not only requirements of departmental Policy but of the CLC.

2. Manager and Supervisor Workplace Inspections

The Loss Control Manual (LCM) dictates that managers and supervisors are required to perform a safety inspection of their workplace at least twice per year. Apart from officers in the CCG Fleet, very few DFO managers/supervisors are aware of this requirement and hence do not perform these inspections. Most believe that the inspections undertaken by the OHS Site Committees are all that is required. Module 4, Workplace Inspection for Managers and Supervisors, provides managers and supervisors with the knowledge and skills necessary to carry out a workplace inspection. It is anticipated that as more managers and supervisors are trained, workplace inspections will be carried out as per CLC requirements. The CCG is working on a program that will require all shore-based managers and supervisors to conduct formal safety inspections of their workplace twice a year.

3. OHS Site Committee Safety Inspections

In accordance with the CLC and the LCM,OHS Site Committees or the local OHS Representatives must conduct monthly workplace inspections of staffed worksites. The requirement to inspect un-staffed sites is more flexible with inspection frequency linked to site specific risk factors. Members of Site Committees and local OHS Representatives undertake these basic work place safety inspections.
The Audit Team did review a sample of staffed site inspection programs. The inspections were carried out diligently with adequate processes in place to ensure deficiencies were corrected.
There are very weak controls in some regions pertaining to the frequency requirements of site inspections. Table 1 below provides data on site inspection frequency by region. This data reveals shortcomings in meeting the site inspection requirements of the CLC, particularly in the Pacific and Quebec regions. The Headquarters OHS Unit is working with the regions to improve the site inspection program, especially for un-staffed sites.

WORKPLACE INSPECTIONS 2004

REGION	Staffed sites	Number completed	Staffed Sites Inspected	Unstaffed Sites	Number Completed	Unstaffed Sites Inspected
Pacific	136	19	14%	1728	10	1%
C&A	31	23	74%	2500	Unreported	Unreported
NCR	8	7	88%	2	1	50%
Quebec	19	12	63%	809	0	0%
Gulf	27	27	100%	440	10	2%
Maritimes	74	62	84%	515	227	44%
Newfoundland	77	73	95%	892	0	0%
National Totals	364	223	61%	6886	248	6%

4. International Safety Management System CCG Fleet Audit Program

The CCG Fleet Safety Management System has a rigorous compliance audit process in place whereby vessels are audited for compliance to ISM policies, both by internal Fleet auditors as well as periodically by accredited external auditors. A process is in place to ensure that any deficiencies identified are signed off as being rectified by senior CCG accountable managers.

5. Formal OHS Audits

The LCM, Chapter 2 states the following:

"It is DFO policy that comprehensive systematic audits of the Occupational Health, Safety and Loss Control Program are carried out by responsible, trained individuals in compliance with commercially recognized safety program protocol."
A program of annual, scheduled, formal audits is the foundation of an effective OHS Program. Formal OHS program audits are far more in-depth than site safety inspections undertaken by local OHS Site Committee members. Formal OHS audits follow specific audit criteria. In DFO the standard that has formally been adopted is the Det Norske Veritas, International Safety Rating System.
A nationally coordinated departmental OHS system audit program using the above referenced DFO standard does not exist in DFO. The last occasion when a series of departmentally orchestrated OHS audits were carried out in the DFO was in 1998.
The level of expertise and effort required to satisfactorily complete a formal OHS audit has been in the recent past beyond the capability of most regional OHS staff. Regions, however, have begun to train some of their OHS Advisors to perform formal OHS program audits.
The CCG did request that the Headquarters OHS Unit coordinate the formal auditing of most of its bases in 2003/2004. This was requested by the CCG to address concerns pertaining to work environment safety issues at CCG bases. These audits were not part of what could be considered a departmental OHS audit program.

The audits conducted of CCG bases were carried out by contract auditors. The auditors applied a rigorous, detailed version of the departmentally approved audit standard to their audits. This resulted in most CCG bases scoring very low in relation to this standard. The Quebec Region in particular felt the audit standard used was unfair. Headquarters OHS Unit management had instructed the auditors to apply this rigorous standard to obtain a baseline from which to measure future improvements. Unfortunately this rationale was not conveyed to the Quebec Region with the resulting regional perception that the audits did not fairly reflect the safety status of the CCG bases.

Conclusion

The current process which monitors adherence to key CLC and DFO LCM requirements for OHS Committee meetings is not sufficiently timely when undertaken on an annual basis as it is in some regions and at the national level. This, along with a lack of awareness of the importance of complying with the CLC results in non-compliant situations not being effectively dealt with.
Most managers and supervisors are not aware of the requirement to undertake regular workplace inspections. Planned training should provide greater awareness of this responsibility.
Local site inspections carried out by Site OHS Committee members and local site OHS representatives do identify basic site safety deficiencies. Processes are in place to help ensures identified deficiencies are addressed. Improved monitoring data is required to ensure that site inspections annually cover all areas within a site.
The lack of a formalized, risk-based OHS system audit program is in contravention of the departmental Loss Control Manual (LCM) and the CLC. The absence of this program seriously inhibits the Department’s ability to systematically and thoroughly identify and rectify workplace safety hazards.

3.2.4 Requirement for the Implementation of a Safety Management System

A more systematic approach, as embodied in a Safety Management System (SMS) is required to successfully implement and maintain an effective OHS Program.
A SMS is an integrated and systematic approach to the implementation of a safety program which identifies and prioritizes safety risks and implements procedures and controls to prevent or minimize these risks. These systems are characterized by clearly defined safety procedures, safety training programs, supporting documentation, regular safety monitoring programs and active management leadership and support.
The CCG Fleet organization implemented a SMS in 1999 in response to a growing acceptance in the international marine community for the adoption of comprehensive SMSs to mitigate the risks associated with fleet operations. This SMS is known within the CCG Fleet as the International Safety (ISM) Management System. This system establishes very specific, well documented procedures and processes for safeguarding Fleet personnel and equipment. Adherence to these processes is established as mandatory within the Fleet and compliance is monitored and audited both internally by CCG Fleet staff and also by external, internationally accredited OHS Auditors.

The implementation of the ISM in the CCG Fleet has not yet resulted in major reductions in accident rates, however, this can to a great extent be linked to the increased risks associated with an aging workforce as well as equipment. The ISM has, however, resulted in a much stronger safety culture in the organization with correspondingly safer operations. The CCG Fleet is confident that the value added of having implemented the SMS will start to show in significantly reduced accident statistics.
In 1999, DFO purchased the organization-wide rights to a Safety Management System developed by Det Norske Veritas (DNV), an internationally recognized authority on OHS. The purchase price for these rights was $1.2 million. This system is based on the International Safety Rating System (ISRS). The DNV package has been used to facilitate the development of the DFO OHS training modules and provide criteria frameworks as guidance for OHS audits. However, no coordinated departmental effort has been made to use the package to facilitate the implementation of a comprehensive OHS SMS in the Department.
The Audit Team found that as a result of the lack of a coordinated initiative to implement a comprehensive department-wide SMS there is significant variability in workplace safety procedures and processes throughout DFO. Apart from the CCG Fleet and a few examples of site specific SMSs, for example, the Institute For Oceans Science in the Pacific Region, the Audit Team did not find evidence of the current existence of a comprehensive approach to the implementation of a SMS in DFO
There are, however, examples nationally and in all regions of the implementation of elements of a SMS. Nationally, the existence of the OHS LCM and the Safety and Security Accountability Framework are important building blocks that are part of a SMS. Regionally, an extensive Task Hazard Analysis (THA) has been carried out at the CCG Sorel Base to identify the hazards associated with the various industrial tasks in the CCG shore-base environment. This initiative was coordinated by the Headquarters OHS organization and has resulted in the development of standard safe operating procedures that are being implemented at CCG bases in the Quebec and Central and Artic regions. The Maritimes and Newfoundland regions were also completing, in parallel, similar THA initiatives in the CCG Integrated Technical Services area. We found little integration between these similar initiatives.
The Maritimes Science organization has also developed THAs and associated safe operating procedures for many of the activities involved in the Science function. These procedures are applied at both major Science institutes in the Maritimes Region demonstrating a comprehensive, region-wide approach to ensuring the adoption of common safe operating procedures in the Region. These procedures have not been disseminated to other regions.
The Audit did identify a major new initiative to implement a region-wide SMS in the Pacific Region. The origin of this initiative was a combined OHS and Environment SMS implemented at the Region’s Institute of Oceans Science (IOS). The Pacific Region Management Committee made the decision in April 2005 to begin implementing the key elements of this combined OHS/Environmental Safety Management System region-wide. In addition, the Pacific CCG organization has also made the decision to take steps to begin the implementation this SMS for all shore-based CCG operations to complement the ISM system already in place in the Fleet. Subsequently in April, the CCG Management Board endorsed a plan to move towards the implementation of a SMS based on the Pacific OHS/Environmental SMS throughout the entire CCG shore-based organization.

The Headquarters OHS Unit is working with representatives from these initiatives to help ensure that any SMSs that are developed are done so within the overall context of the departmental SMS framework as embodied in the DNV Safety Management System purchased by the Department in 1999.
The importance of a more structured and systematic approach to OHS has been recognized by the Labour Program of HRSDC. As a result, new regulations "The Hazard Prevention Program Regulations" have been drafted and are expected to become law within the next 12 to 18 months. These regulations will oblige all federally regulated organizations to ensure they address OHS considerations not through a series of OHS initiatives but through a well coordinated and systematic OHS Program.

Conclusion

The only comprehensive national SMS currently in place in DFO is the ISM implemented in the CCG Fleet organization. Plans to introduce a SMS into the Pacific Region and nationally into shore-based CCG operations will once implemented, significantly increase the number of DFO workplaces and employees that will benefit from the consistent development and application of safe working practices that are inherent with the implementation of a SMS.
The implementation of a SMS in the remainder of the Department would increase assurance that all DFO work sites and employees would benefit from a common standard of safety that is subject to continuous, systematic improvement. A department-wide coordinated approach to OHS through the implementation of a SMS would also clearly demonstrate due diligence on the part of all managers in the DFO OHS accountability chain.

3.2.5 Recommendations – Policies Guidelines and Processes

Recommendation 7

The Director of Safety and Security, in conjunction with the Regional Directors of Safety and Security should ensure that a departmental OHS system is developed which can track all key OHS related activities as well as effectively and efficiently report on them.

Recommendation 8

The Director of Safety and Security, in conjunction with the Regional Managers of Safety and Security should develop a comprehensive, risk-based OHS monitoring program. This program should include more frequent monitoring where there is a history of non compliance to departmental OHS policy as well as a formal departmental OHS system audit program.

Recommendation 9

The Director of Safety and Security, in conjunction with the Regional Managers of Safety and Security should:

Provide guidance and direction in support of the initiative within the CCG and in the Pacific Region to develop and implement an integrated Health, Safety and Environmental Management System (HSEMS) to ensure that it effectively follows the framework inherent in the departmental Safety Management System and is cost effective.
Concurrently, provide guidance and direction in the remaining regions to support the implementation of a SMS in all areas/sectors of the Department not covered by a comprehensive SMS.

3.3 Planning, Risk Management and Performance Measurement

3.3.1 Risk-based OHS Planning

Findings

The Business Case and associated OHS Accountability Framework presented to DMC in the spring of 2004 to justify additional resources for regional OHS initiatives was in effect, a comprehensive, high-level risk-based OHS plan. The Accountability Framework identified the key generic OHS activities that should be performed, with the roles of the Headquarters OHS Unit differentiated from the regional OHS Units.

This generic national plan, derived from the Business Case, however, is not a valid Operational Plan which focuses specific activities which are planned for the coming 12 to 18 months. The Pacific, Quebec and Maritimes regions did develop an OHS Operational Plan for 20004/05 which set out planned initiatives and associated FTEs and dollar resource requirements. The Central and Arctic and the Gulf regions did not develop such a plan. The Newfoundland Region created more of a budget statement which identified planned resource expenditures against budgetary items. From a regional perspective, the implementation of any OHS plans that were developed was made difficult because of the delays in approving the staffing of newly funded Regional OHS Advisor positions.

The Headquarters OHS Plan for 2004/05 is essentially a list of projects and activities that each Headquarters OHS staff member planned to undertake in the fiscal year. There is no estimated level of effort associated with the planned activities nor any stated reference to their priority. In addition, there was little consultation with regional OHS units in the development of the plan. Without some effort to estimate the level of effort required for each planned activity, there can be little assurance that the plan can be accomplished.

Conclusion

The current planning processes supporting the Headquarters and regional OHS function are not sufficiently risk-based, nor comprehensive to be considered viable planning instruments.

3.3.2 Monitoring of OHS Plans

Findings

The monitoring of degree of achievement to planned action is an essential component of an effective management framework. The audit found there are mechanisms in place which have the potential to provide the framework for an effective system to monitor the degree to which OHS plans and objectives are achieved. As referenced above, Section 3.1.3 Accountability for OHS Related Resource Allocations, a Service Level Agreement (SLA) was developed for the fiscal year 2004/05 between the ADM HR&CS and the RDGs. This SLA committed to the completion of the OHS policy framework, the ongoing initiative to deliver OHS training in regions and the effective use in the regions of the new incremental regional OHS funding. Unfortunately, no mechanism has been established at the national level to monitor the extent to which planned initiatives are actually carried out. Apart from progress on the provision of OHS training, the Headquarters OHS Functional Authority does not track, monitor or ask regions for any status as to whether planned activities have been achieved.
In most regions and in Headquarters the Accountability Accords for senior executives with direct line responsibility for OHS units, for example the Director of Corporate Services in regions, do specifically make reference in the Key Commitments to planned initiatives of the OHS organization for which they are accountable. The degree of achieving these commitments is reported annually within the region as part of mandatory performance reporting process associated with formal Accountability Accords.

Conclusion

The use of SLAs to provide accountability between the ADM and RDGs pertaining to the achievement of planned OHS initiatives has the potential to be an effective monitoring tool once adequate followed-up procedures are implemented. The departmental Accountability Accord process associated with executives who have OHS Functional Authority at the Headquarters and regional level, could become more relevant as a monitoring tool once the OHS planning process is improved.

3.3.3 Recommendations Planning Risk Management and Performance Measurement

Recommendation 10

The Director of Safety and Security, in conjunction with the Regional Managers of Safety and Security should develop and implement a risk-based OHS Business and Operational Planning Process.

Recommendation 11

The ADM of Human Resources and Corporate Services and the Regional Director Generals should expand the use of Service Level Agreements to include key elements of annual OHS risk-based Operational Plans. A process to monitor performance in achieving Service Level Agreement commitments should be part of this performance measurement process.

3.4 OHS Training and Awareness and Competencies,

3.4.1 Departmental Management and Staff OHS Training and Awareness

Overview

The CLC and the Treasury Board OHS Policy requires that departments provide the information, instruction and training necessary to ensure the health and safety of employees at work. Every employer is responsible to ensure that employees who have supervisory or managerial responsibility are adequately trained in health and safety and are informed of the staff responsibilities they have where they act on behalf of the employer.

Prior to 2002, there was not a consistent approach to OHS training in the Department. Training was carried out sporadically by DFO managers in various areas of the organization. Some managers took the initiative of taking courses on their own and had their staff either attend courses or brought the expertise in-house to provide training.

In the 2002, the Treasury Board Secretariat initiated a government wide project to bring government departments together in the development of standard OHS training. The goal was for departments to share their resources, come up with OHS training suitable for interdepartmental use and make it available for other departments.

DFO decided to develop OHS course modules within the Department when there were significant delays in progress on the inter-departmental initiative. Six, four-hour OHS training modules, were developed by the Headquarters OHS Unit to provide training to managers, supervisors and staff to inform them of their responsibilities under Part II of the Canada Labour Code and of the tools available in DFO to assist them in meeting these obligations. These training modules were developed and piloted in 2003 and released for use in January 2004.

A seventh training module on the roles and responsibilities of OHS Committee Members and OHS site representatives was later developed.

Findings

A course evaluation program has been developed as part of the development of the OHS course modules themselves. Course participants are asked to respond to a questionnaire at the end of each course delivery. To date evaluations for the modules delivered thus far indicate the modules are viewed as providing effective and useful OHS training.
No evaluation strategy has been developed to measure the long-term effectiveness of the current OHS training program.
DMC set the end of 2004/05 as a target for all managers and supervisors to attend the four-hour training session on the OHS Module 1 "Introduction to OHS Roles and Responsibilities of DFO Managers and Supervisors". The training, however, was not made mandatory at the departmental level. To encourage regions to complete this Module 1 training, quarterly training progress reports were monitored by the National Policy Health and Safety Committee.
Some regions, notably Newfoundland, Maritimes and Quebec Regions placed a high priority on completing this training and promoted this course as mandatory for managers and supervisors. These Regions have made excellent progress in ensuring this training is provided. In the National Capital, Central and Arctic and Pacific Regions, Module 1 was not given the status of mandatory. Far fewer managers and supervisors have been trained. In addition, the lack of mandatory status in these regions resulted in significant inefficiencies in course delivery as trainers often instructed class sizes much lower than capacity.
The only nationally developed strategy for implementing the departmental OHS Training Program was one that focused exclusively on the initial provision of Module 1 training to managers and supervisors. No provision was made in this initial national training strategy to provide OHS training to departmental staff. It was left up to the Regions to develop and implement their own OHS training strategies.

Module 2, Conducting OHS Awareness Sessions, is a module developed to provide managers and supervisors with the knowledge and support material necessary to provide important basic OHS training to their staff. Both Modules 1 and 2 are four hours in length. In most regions an opportunity was missed to provide both these modules together. This would have created greater efficiencies in course delivery associated with travel as well as greatly expedited the delivery of OHS training to DFO staff. Only the Maritimes Region created a training strategy that included the initial delivery of Module 1 and 2 as well as several other modules.

The following table shows the progress made by each DFO Region in completing the various modules associated with the DFO OHS Training Program.

[Click on picture to enlarge]
Chapter 20 of the DFO LCM states the requirement to ensure all new employees are provided with adequate OHS orientation training. No comprehensive department-wide strategy has been developed for orientation training of new managers or staff to ensure they are provided adequate OHS orientation training. OHS handbooks are available at the departmental OHS web site however the availability of this training material does not constitute a bonafide training strategy.

In the National Capital Region there is a general, non-mandatory, orientation course which includes only minimal reference to OHS. The Newfoundland Region does conduct an annual OHS course for new employees, however, the course is given in the Regional Office with no assurance that all new staff actually attend. Several DFO organizations, for example, the Bedford Institute for Oceans, Maritimes Region, have developed OHS orientation manuals which cover key generic as well as site specific safety issues. However, there is no department-wide program to ensure that all new DFO employees are provided with an appropriate, comprehensive OHS orientation program.

Conclusion

The Department does not have an effective, risk-based OHS training and awareness strategy which covers required OHS training for DFO employees. The focus in most regions on the initial delivery of only the Module 1 Introduction to OHS Roles and Responsibilities of Managers and Supervisors, has resulted in missed opportunities to provide OHS training to departmental staff in an efficient and timely manner.
An overall risk-based departmental OHS training and awareness strategy which includes all aspects of initial employee training as well as ongoing and orientation training would significantly enhance the effectiveness and efficiency of the DFO OHS Training Program.

3.4.2 Training of OHS Professionals

Findings

DFO does not presently have a formally recognized statement of competencies for its OHS professionals linked to approved training courses that address specific competency gaps.
At the time of the audit an initiative was underway to develop OHS manager and OHS Advisor competency profiles and associated training requirements. Although these had not been completed, some regions had become proactive in committing to hiring new staff with industry recognized OHS designations.

Conclusion

The finalization of the generic national OHS Manager and Advisor Job Descriptions and accompanying required Competency Profiles, will greatly facilitate the creation and implementation of an effective, competency-based training and certification program for DFO OHS professionals.

3.4.3 Recommendation OHS Training and Awareness

Recommendation 12

The Director Safety and Security, in conjunction with the Regional Managers of Safety and Security, should develop a comprehensive, risk-based OHS training and awareness strategy. This should include all aspects of initial employee training as well as ongoing and orientation training.

4.0 MANAGEMENT ACTION PLAN

OCCUPATIONAL HEALTH AND SAFETY (OHS) MANAGEMENT ACTION PLAN
Recommendations	Management Action Plan	Initial Target Date	Actions completed	Actions Out-standing	Estimated Completion Date
OHS Management Structure 1. The ADM of HRCS should develop processes to improve the controls associated with the expenditure of new incremental resources allocated for specific functions.	Regional allocations will be transferred under ADM HRCS signature. Regional Directors General (RDGs) will account for their OHS resource utilisation in conformance with approved Service Level Agreements (SLAs) and Business Plans.	April 2006
2. The DM should monitor, through the Accountability Accords with ADMs and RDGs, the adherence to key departmental OHS policies and initiatives, with initial emphasis on the meeting frequency requirements for Regional and Site OHS committees.	Accountability for OHS will be built into the Ongoing Commitments section of the ADM, RDG and Commissioner- & Assistant Commissioner-CCG accountability accords.	April 2006
	As a first step in compliance assurance, RDGs/ACs-CCG will ensure that Regional and Workplace OHS committees meet in accordance with the requirements of Part II of the Canada Labour Code and Departmental policy. Regional 4 times/year Workplace (at least) 9 times/year	December 2005
	RDGs/ACs will ensure that the reporting structure is in place to maintain up-to-date data on compliance with Part II and ensure that the required reports are made to Director S&S in a timely fashion.	February 2006
	The Director of S&S will monitor compliance data nationally.	January 2006
	Regional Managers of S&S will provide more support to Regional Health and Safety Committees (RHSCs), e.g.: Training for committee members Advice and guidance Data collection and compilation (Audit, 3.1.4, Conclusion, page 10)	February 2006
3. The DM should ensure that significant OHS issues and initiatives are included quarterly on the agenda of the DMC.	The Management Chair of the National Policy Health and Safety Committee (NPHSC), with the Director S&S, will report quarterly to DMC on significant OHS initiatives and issues, including on the progress made to implement the departmental OHS program. Note: The Corporate OHS section provides the secretariat function for the NPHSC.	January 2006
	At these sessions, RDGs will present quarterly reports on significant regional OHS issues on behalf of RHSCs. (CCG-Assistant Commissioners (ACs) covered through membership on and input to RHSCs)	January 2006
	Regional Managers S&S will provide support to the RDG/RHSC in preparing these reports.	December 2005
4. The DM should ensure that OHS-related communication is formally enhanced between: The Director S&S and the DM at the HQ level; and Regional Managers of S&S, and RDGs as well as RDs-CCG. This should be accomplished by: 1) Including in their job descriptions a “dotted line” reporting relationship pertaining to the OHS function between: the Director of S&S and the DM. the Regional Manager of S&S and the RDG 2) By instituting quarterly OHS key issue briefings between: the Director of S&S and the DM the Regional Managers of S&S and their respective RDGs and RDs-CCG.	Implement the recently approved Safety and Security Policy and Accountability Framework which defines the relationships between the Director S&S and the DM/Commissioner CCG, and the Regional Managers S&S and the RDGs/ACs-CCG (Ref. item 3: quarterly reporting to DMC will improve communications.)
	Generic position descriptions for the Director S&S and Managers of S&S will include “dotted-line” reporting relationships with the DM/Commissioner CCG and the RDGs/ACs for urgent OHS matters (Ref. Recommendation # 3) Deputy Minister will monitor the effectiveness of the dotted-line reporting structure and intervene where appropriate to lend support to the OHS functional authority. (Audit, 3.1.6, Conclusion, page 12)	April 2006
	For issues related to quarterly reports see Recommendation #3	January 2006
5. The DM should ensure that senior departmental managers proactively demonstrate their leadership and support for the departmental OHS program including annual participation in at least one Site Safety Inspection as directed by the departmental OHS Loss Control Manual.	Departmental senior managers will include reports on the actions taken in their sectors and regions to promote the OHS program in the quarterly OHS performance reports to DMC.	February 2006
	Senior managers will participate in at least one site safety inspection per year, as directed in the department’s OHS Loss Control Manual, Chapter 1.3.1 c) ii).	January 2006
	Regional managers of safety and security will advise RDGs and ACs-CCG on steps to take to improve visibility of OHS. These could include: Participating in North American Occupational Health and Safety (NAOSH) Week activities Publishing articles and photos In the Loop that show participation in safety inspections Presenting awards to staff for their contribution to the OHS program, etc.	February 2006
6. The DM should ensure that guidelines and Terms of Reference are developed for the departmental champions for Workplace Wellness and Safety and that annual performance expectations for the role of champion be included in the Accountability Accords for the champions.	Generic Terms of Reference for all departmental champions were approved by DMC.
	Specific expectations for any Champion with OHS-related responsibilities will be set out in the Accountability Accord for that individual.	February 2006
Policies and Guidelines 7. The Director S&S, in conjunction with the Regional Managers S&S should ensure that a departmental OHS system is developed that can track all key OHS-related activities as well as effectively & efficiently report on them. 8. The Director S&S, in conjunction with the Regional managers of S&S should develop a comprehensive, risk-based OHS monitoring program. This program should include: more frequent monitoring where there is a history of non-compliance to departmental OHS policy; as well as a formal departmental OHS system audit program.	Note: this recommendation relates to the data monitoring component (hardware & software) of the departmental OHS system. Director and Regional Managers S&S will:
	Conduct a needs analysis to identify data tracking and reporting deficiencies and required enhancements. Initial focus will be on the PeopleSoft (PS) OHS and Training modules (since PS is likely to be the system ultimately used by Services Canada).	March 2006
	Present the results of the analysis to DMC.	May 2006
	DMC will make it a priority for PS to provide the needed enhancements. Note: Monitoring of a number of key CLCII accountabilities is currently underway. Program currently covers OHS committee meetings & staffed-site workplace inspections, manager & supervisor training & accident reporting. The Director and Regional Managers S&S will develop and implement a risk-based OHS monitoring program that includes national and regional compliance assurance schedules.	March 2006
	Director and Regional Managers, S&S: HQ& Regions will develop strategy to allow RHSC to monitor workplace inspection activity.	March 2006
	HQ& Regions currently developing strategy to improve site inspection program for unstaffed sites.	March 2006
	Director S&S will review LCM OHS policies and recommend measures to monitor compliance to key departmental policies.	March 2006
	Director & Regional Managers S&S will develop a strategy to perform systematic audits of the departmental OHS program. Director S&S will produce an OHS program audit schedule based on risk management principles.	June 2006
	Audit Program proposal and methodology will be presented to DMC for approval. HQ and Regional Senior Managers will participate in at least one workplace inspection per year. (ref. Recommendation 5)	September 2006
9. The Director of S&S, in conjunction with the Regional Managers of S&S should: Provide guidance and direction in support of the initiative within CCG and the Pacific Region to develop and implement an integrated Health, Safety and Environmental Management System (HSEMS) to ensure that it effectively follows the framework inherent in the departmental SMS and is cost-effective. Concurrently, provide guidance and direction in the remaining regions to support the implementation of a SMS in all areas/sectors not covered by a comprehensive SMS.	The DG Real Property Safety and Security (RPSS) will participate on the CCG-P and Pacific Region HSEMS steering committees to ensure that the HSEMS effectively follows the departmental framework inherent in the departmental SMS and is cost effective.	Action immediately
	Pacific Region will develop, with advice and guidance from HQ S&S and the Office of Environmental Coordination (OEC), a risk-based needs analysis for the HSEMS project. Once the risk-based needs analysis is complete, all parties will collaborate to set priorities and develop targets for program implementation.	February 2006
	The Corporate OHS Centre of Expertise (COE), in concert with the Corporate OEC, provides on-going advice and guidance to management and the HSEMS project coordinators on the HSEMS initiative.	Ongoing
	Corporate OHS & OEC will identify the commonalities in their programs. Corporate OHS & OEC will make recommendations on coordination of work between the two groups.	March 2006
	The Director of S&S holds bi-weekly teleconferences with all Regional Managers of S&S to discuss new issues and the status of ongoing OHS projects to improve DFO’s SMS.	Ongoing
	Twice each year, the Managers of Safety and Security meet to discuss the OHS program and plan activities to implement the DFO SMS.	Ongoing
	A Strategic Investment Fund (SIF) has been created to fund projects that will further the implementation of the departmental SMS.	Ongoing
	SIF activities planned for 2005-2006: SCH Safety Inspection & Procedures Manual (lead: NL) Critical Task/Task Hazard Analysis C&P Quebec Region (lead: Qué.) Training Plan for OHS Advisors (see audit recommendation 12) (lead: corporate OHS)	March 2006 March 2007 March 2006
10. The Director S&S, in conjunction with the Regional Managers of S&S should develop and implement a risk-based OHS Business and Operational Planning Process.	The Director and Regional Managers S&S will develop and implement a risk-based operational planning process which includes a formal assessment of costs/benefits and risks. As specified in the Audit, 3.3.1, page 24, the process will: Define key activities focus on the operations and specific activities that are achievable within 12-18 months contain estimated level of effort contain estimated FTEs & cost of resources needed set priorities contain estimated completion dates	April 2006
11. The ADM of HRCS and the RDGs should expand the use of Service Level Agreements to include key elements of annual OHS risk-based Operational Plans. A process to monitor performance in achieving SLA commitments should be part of this performance measurement process.	The ADM HRCS and the RDGs/ACs will expand the use of service level agreements to include key specific OHS accountabilities, priorities and requirements. Director and Regional Managers S&S will provide advice and guidance as needed. Achievements and areas for improvement will be summarized in the quarterly OHS performance reports to DMC and the RMCs (ref: Recommendation 3).	April 2006
12. The Director S&S, in conjunction with the Regional Managers of S&S, should develop a comprehensive, risk-based OHS training and awareness strategy. This should include all aspects of initial employee training as well as ongoing and orientation training.	Departmental Training OHS training to meet the CLCII requirements will be made mandatory nationally. The Director S&S will prepare a DM notification to all staff informing them of the training requirements.	December 2005
	Director & Regional Managers S&S will develop a comprehensive national strategy on training delivery that will include recommendations on e-learning. The strategy will take into consideration OHS employee orientation and other types of training that may be approached from a national or regional perspective (e.g.: WHMIS)	October 2006
	Director & Regional Managers S&S will develop a means to evaluate the long term effectiveness of OHS training.	March 2007
	OHS Advisor training Corporate Safety and Security is developing an organizational design proposal, competency profiles and National Model Work Descriptions that will apply to the Safety and Security Program nationally. The training strategy for OHS professionals will be developed in line with the competency profiles project.	March 2006

Appendix A - List of Audit Recommendations

Recommendation 1

Recommendation 2

Recommendation 3

The Deputy Minister should ensure that significant Occupational Health and Safety issues and initiatives are included quarterly on the agenda of the Departmental Management Committee.

Recommendation 4

The Deputy Minister should ensure that OHS related communication is formally enhanced between:

- The Director Safety and Security and the Deputy Minister at the Headquarters level; and

- Managers of Safety and Security, and Regional Director Generals and Assistant Commissioners CCG at the regional level.

This should be accomplished by:

Including in the Job Description of the Director of Safety and Security, a “dotted line” reporting relationship, pertaining to the OHS function, between the Director and the Deputy Minister.
Including in the Job Description of Regional Managers Safety and Security a “dotted line” reporting relationship, pertaining to the OHS function, between the Regional Manager Safety and Security position and the Regional Director General.
Instituting quarterly OHS key issue briefings between the Director of Safety and Security and the Deputy Minister, and the Regional Managers of Safety and Security and their respective Regional Directors General and Assistant Commissioners of CCG.

Recommendation 5

Recommendation 6

The Deputy Minister should ensure that guidelines and Terms of Reference are developed for the departmental Champions for Recognition and Workplace Well-being and that annual performance expectations for the role of Champion be included in the Accountability Accords for the Champions

Recommendation 7

Recommendation 8

Recommendation 9

The Director of Safety and Security, in conjunction with the Regional Managers of Safety and Security should:

Provide guidance and direction in support of the initiative within the CCG and in the Pacific Region to develop and implement an integrated Health, Safety and Environmental Management System (HSEMS) to ensure that it effectively follows the framework inherent in the departmental Safety Management System and is cost effective.
Concurrently, provide guidance and direction in the remaining regions to support the implementation of a SMS in all areas/sectors of the Department not covered by a comprehensive SMS.

Recommendation 10

The Director of Safety and Security, in conjunction with the Regional Managers of Safety and Security should develop and implement a risk-based OHS Business and Operational Planning Process.

Recommendation 11

Recommendation 12

Common menu bar links

Institutional links

Reports

Resources

Proactive Disclosure

Audit of the Departmental Occupational Health and Safety Management Control Framework

Table of Contents

1.0 EXECUTIVE SUMMARY

2.0 Introduction

2.1 Background

2.2 Objectives and Scope

2.3 Methodology

2.4 Lines of Enquiry and audit criteria

3.0 Observations and Recommendations

3.1 OHS Management Structure

3.1.1 Overview

3.1.2 Organizational Structure

3.1.3 Accountability for OHS Related Resource Allocations

3.1.4 OHS Committees

3.1.5 OHS Roles, Responsibilities and Accountabilities

3.1.6 OHS Functional Authority

3.1.7 Communication with Senior Management

3.1.8 Leadership

3.1.9 Recommendations – OHS Management Structure

3.2 Policies, Guidelines, Processes and Systems

3.2.1 Departmental OHS Policies

3.2.2 OHS Systems

3.2.3 Monitoring the Implementation of OHS Policies and Program

3.2.4 Requirement for the Implementation of a Safety Management System

3.2.5 Recommendations – Policies Guidelines and Processes

3.3 Planning, Risk Management and Performance Measurement

3.3.1 Risk-based OHS Planning

3.3.2 Monitoring of OHS Plans

3.3.3 Recommendations Planning Risk Management and Performance Measurement

3.4 OHS Training and Awareness and Competencies,

3.4.1 Departmental Management and Staff OHS Training and Awareness

3.4.2 Training of OHS Professionals

3.4.3 Recommendation OHS Training and Awareness

4.0 MANAGEMENT ACTION PLAN

Appendix A - List of Audit Recommendations