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Internal Audit Report

Audit of Emergency Preparedness

Project 6B260

December 5, 2014

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TABLE OF CONTENTS

1.0 EXECUTIVE SUMMARY
2.0 BACKGROUND
3.0 AUDIT OBJECTIVE
4.0 AUDIT SCOPE
5.0 AUDIT APPROACH
6.0 AUDIT FINDINGS
7.0 AUDIT OPINION
8.0 STATEMENT OF CONFORMANCE
APPENDIX A — AUDIT CRITERIA

1.0  EXECUTIVE SUMMARY

Emergency management is comprised of four pillars: prevention/mitigation, preparedness, response and recovery. Emergency preparedness encompasses the measures and planning activities to ensure a government institution is ready to respond quickly and effectively to an emergency and manage its consequences through measures taken prior to an emergency event1. To this end, Public Safety Canada recommends that government institutions adopt an all-hazards approach to implement the necessary activities aimed at building, sustaining and continually improving their capability to respond effectively to large-scale emergencies and to reduce the potential of loss of life and personal injuries.

As a supporting department to primary departments, Fisheries and Oceans Canada is responsible for providing assistance in nine (9) of the thirteen (13) Emergency Support Functions identified in the Federal Emergency Response Plan. In order to fulfill its responsibility under the Federal Emergency Response Plan, Fisheries and Oceans Canada has developed a Strategic Emergency Management Plan which outlines, at a strategic level, the Department’s objectives, approach and governance.
 
The audit examined whether the departmental internal structure, processes, and controls for emergency preparedness were adequate to position the Department for a coordinated and effective response to Public Safety Canada in its role as a supporting department. Based on the audit findings, our opinion is that, while the Department has demonstrated its capacity to respond to an emergency, the audit revealed opportunities for improvement in terms of formalizing and refining the internal structures, processes, and controls in order to ensure a more coordinated and efficient departmental response. Specifically, improvements should be made to clarify roles and responsibilities and to ensure a more unified departmental approach to emergency preparedness in an effort to improve its capability to respond to emergency events in a more efficient and effective manner. The recommended improvements are as follows:

  • Ensure that the roles and responsibilities for emergency preparedness at the operational level are clearly defined and communicated across all sectors and regions of the Department, as well as the Canadian Coast Guard.
  • Review the current structure to identify opportunities for better integration, coordination and communication between the Canadian Coast Guard and Fisheries and Oceans Canada both at National Headquarters and in the regions;
  • Operationalize the Strategic Emergency Management Plan, including the development of protocols, processes, and regional emergency management plans;
  • Conduct joint exercises to validate and test the governance structure and the concept of operations presented in the Strategic Emergency Management Plan and its corresponding operational plans, as appropriate; and
  • Consider establishing a monitoring mechanism for emergency preparedness activities once implemented to ensure the Department’s continued compliance with relevant legislations and policies.

Management Response

Management is in agreement with the audit findings, has accepted the recommendations included in this report, and has developed a management action plan to address them.  The management action plan has been integrated in this report.


1 An Emergency Management Framework for Canada - Second Edition, January 2011, Public Safety Canada.

2.0 BACKGROUND

An emergency is defined as a present or imminent event that requires prompt coordination of actions concerning persons or property to protect the health, safety or welfare of people, or to limit damage to property or the environment2. In Canada, when an emergency is local in nature, it is handled by the municipality and province or territory. However, if the emergency escalates beyond their capacity to respond or falls within federal jurisdiction, the federal government intervenes by providing help to manage and coordinate the emergency response.

Established through the Emergency Management Act, and government policy, Public Safety Canada is the agency responsible to exercise leadership for emergency management in Canada by coordinating emergency management activities among federal departments and agencies. Depending on the type of emergency, some departments have been identified as playing a primary role in providing assistance given their mandate. For example, the Royal Canadian Mounted Police is the primary agency to provide law enforcement support. However, if the emergency escalates, other federal departments, known as supporting departments or agencies, may be asked to play a supporting role to manage the impact within their area of expertise. The processes and mechanisms to facilitate an integrated Government of Canada response are outlined in the Federal Emergency Response Plan.

Under the Emergency Management Act, federal departments and agencies are also mandated to develop emergency management plans in respect of the risks that are within or related to their area of responsibility. In addition, departments and agencies are responsible for preparing, maintaining, testing, and implementing emergency management plans, as well as conducting exercises and training in relation to those plans.

Emergency management is comprised of four pillars: prevention/mitigation, preparedness, response, and recovery. Emergency preparedness encompasses the measures and planning activities to ensure a government institution is ready to respond quickly and effectively to an emergency and manage its consequences through measures taken prior to an emergency event. To this end, Public Safety Canada recommends that government institutions adopt an all-hazards approach to implement the necessary activities aimed at building, sustaining, and continually improving their capability to respond effectively to large-scale emergencies and to reduce the potential of loss of life and personal injuries.

As a supporting department to primary departments, Fisheries and Oceans Canada, including the Canadian Coast Guard, is responsible for providing assistance in the following nine (9) Emergency Support Functions identified in the Federal Emergency Response Plan: Transportation; Telecommunications; Agriculture and Agri-Food; Public Health and Essential Human Services; Environment; Law Enforcement; Logistics Operations Management; Communications; and Border Services.

Within Fisheries and Oceans Canada, the National Emergency Services group, which resides within the Safety, Security, and Emergency Services directorate of the Human Resources and Corporate Services sector, provides advice and support to senior management at National Headquarters and Safety, Security and Emergency Services staff in the regions. In addition, this group serves as the liaison between the Department and Public Safety Canada for matters related to the Federal Emergency Response Plan at the national level. In parallel, the Safety, Security and Emergency Services staff in the regions also provide advice and guidance to management and programs within their respective regions. They also liaise with Public Safety at the regional level and with provincial emergency management entities. As well, the Canadian Coast Guard also links directly to Public Safety Canada at the national level and in some cases, at the regional or zonal level.

Given the Department’s broad mandate, the Canadian Coast Guard and various sectors are involved in the Federal Emergency Response Plan. For example, the Canadian Coast Guard may be called upon directly by Public Safety Canada to deliver an array of emergency services through its fleet. In turn, Ecosystems and Fisheries Management may play a role in emergency services associated with the protection of fisheries, whereas Ecosystems and Oceans Science may provide emergency assistance on matters related to aquatic science and hydrographic services. In these instances, the National Emergency Services group and the regional Safety, Security and Emergency Services staff serve as a key liaison between the Department and Public Safety Canada to ensure situational awareness of relevant stakeholders on events that have potential or actual impacts on the Department and/or in support of the Federal Emergency Response Plan.

Emergencies in the current environment are broad and complex as they can stem both from natural events (such as floods, earthquakes, ice storms, or infectious disease outbreaks), or man-made disasters (such as hazardous materials spills, cyber-attacks, or terrorist acts). Increasing risks associated with factors such as urbanization, critical infrastructure dependencies and interdependencies, terrorism, climate change, environmental change, animal and human diseases, and the increased movement of people and goods around the world have heightened the need for adequate and effective emergency preparedness.

With these factors in mind, it is important to note that since the coming into force of the Emergency Management Act in 2007, emergency preparedness is still relatively new as it continues to evolve across the federal government. It should also be noted that this evolution has not been without its challenges, which includes some reorganization at Public Safety Canada, an update of the Federal Emergency Response Plan within two years of its initial approval in 2009, and an update of An Emergency Management Framework for Canada four years after its development. Emergency preparedness at Fisheries and Oceans Canada continues to improve as it moves forward with other federal institutions under Public Safety Canada’s leadership.


2  An Emergency Management Framework for Canada - Second Edition, January 2011, Public Safety Canada.

3.0 AUDIT OBJECTIVE

The audit objective was to provide assurance that the Department has adequate internal structures, processes, and controls in place for emergency preparedness to ensure the safety of its people during an emergency, as well as to provide a coordinated and effective response to Public Safety Canada in its supporting departmental role. However, based on findings resulting from work conducted during the engagement conduct phase, the audit team determined that the objective should be refined to focus the audit on key areas pertaining to emergency preparedness.

Therefore, the revised audit objective will be to provide assurance that the Department has adequate internal structures, processes, and controls in place for emergency preparedness to provide a coordinated and effective response to Public Safety Canada in its role as a supporting department.

4.0 AUDIT SCOPE

The scope of the audit was risk-based and focused on the following areas:

  • Governance and strategic direction;
  • Emergency preparedness activities;
  • Monitoring and reporting; and
  • Partnership and collaboration.

While emergency preparedness includes the measures or plans in place to protect employees, safeguard assets, and assure the continued delivery of critical services in the event of an emergency, the audit only focused on the Department’s responsibilities in its role as a supporting department under the Federal Emergency Response Plan. For this reason, the following areas were excluded from the scope of the audit:

  • The safeguard of assets;
  • The quality and comprehensiveness of business continuity plans. An audit of business continuity planning was conducted in 2010 and the resulting management action plans were completed as of June 2014; and
  • The safety of employees and workplace emergencies, as they fall under the Department’s responsibility in its role as an employer, which directly pertains to occupational health and safety.

5.0 AUDIT APPROACH

The audit team carried out its mandate in accordance with the Treasury Board’s Policy on Internal Audit, the Internal Audit Standards for the Government of Canada and the Institute of Internal Auditors’ International Standards for the Professional Practice of Internal Auditing. These standards require that the engagement be planned and performed in such a way as to obtain reasonable assurance that the audit objectives are achieved. As such, the audit employed various techniques including a risk assessment of the audit entity, interviews, as well as reviews and analysis of documentation and information.

6.0 AUDIT FINDINGS

This section provides the observations and recommendations resulting from the audit work carried out. While the audit was conducted based on the lines of enquiry and audit criteria identified in the planning phase, this report is structured along the following main themes:

  • Roles and Responsibilities;
  • Coordination of Emergency Response; and
  • State of Preparedness.

For conclusions by audit criterion, please refer to Appendix A.
 
Based on the audit work performed and our professional judgment, the risk associated with each observation was rated using a three-point scale. The risk ranking (high, moderate and low) is based on the level of potential risk exposure we feel may have an impact on the achievement of Fisheries and Oceans Canada objectives, and is indicative of the priority Management should give to the recommendations associated with that observation. The following criteria were used in determining the risk exposure level:

Criteria Table
High Controls are not in place or are inadequate.
Compliance with legislation and regulations is inadequate.
Important issues are identified that could negatively impact the achievement of program/operational objectives.
Moderate Controls are in place but are not being sufficiently complied with.
Compliance with central agency/departmental policies and established procedures is inadequate.
Issues are identified that could negatively impact the efficiency and effectiveness of operations.
Low Controls are in place but the level of compliance varies.
Compliance with central agency/departmental policies and established procedures varies.
Issues identified are less significant but opportunities that could enhance operations exist.

6.1 ROLES AND RESPONSIBILITIES

As per the Treasury Board Secretariat’s Audit Criteria related to the Management Accountability Framework, governance is articulated through internal coherence, corporate discipline and alignment to outcomes, which are essential conditions in an entity for providing effective strategic direction and ensuring delivery of results.
 
In the context of Fisheries and Oceans Canada’s role as a supporting department under the Federal Emergency Response Plan, a governance function is important to ensure that management’s direction, plans, and actions for emergency preparedness are appropriate and responsible. It defines the required resources and competencies, and ensures that they are sufficient to meet the Department’s objectives pertaining to emergency preparedness. A governance function reinforces accountabilities for results by ensuring that they are clearly assigned and consistent with resources. It also is a mechanism to help ensure that roles and responsibilities are clearly understood so that tasks are performed accordingly and as expected.

Observations Section 6.1
Observations
Low 6.1.1 In general, governance mechanisms are in place to provide direction for emergency preparedness activities. However, roles and responsibilities for the coordination and development of emergency management plans and activities are not clearly defined and communicated, which could create challenges in ensuring a coordinated emergency response with the relevant regions, sectors, and the Canadian Coast Guard.

Under the Emergency Management Act, the Minister of Public Safety is responsible for exercising leadership by coordinating emergency management activities among government institutions and in cooperation with provinces and other entities. As such, Public Safety Canada developed the Federal Emergency Response Plan to harmonize federal emergency response efforts with those of the provincial and territorial governments, non-governmental organizations, and the private sector. Pursuant to the Emergency Management Act, all federal ministers are responsible for developing emergency management plans in relation to risks in their areas of accountability. These individual departmental emergency management plans support the Federal Emergency Response Plan’s strategic objectives and contribute to an integrated Government of Canada response.

The scope of an emergency will determine the role of federal government institutions. Emergency Support Functions provide the mechanisms for grouping functions most frequently used in providing federal support to provinces and territories or federal-to-federal assistance in response to a request for assistance during an emergency. These functions are allocated to federal government institutions in a manner consistent with their respective mandated areas of responsibility. A Primary Department is a federal government institution with a mandate directly related to a key element of an emergency. A Supporting Department is a federal government institution that provides general or specialized assistance to a primary department in response to an emergency due to their having specific capabilities or resources which support the Primary Department in executing the mission of the Emergency Support Function. Fisheries and Oceans Canada provides a supporting role to the following nine (9) Emergency Support Functions identified in the Federal Emergency Response Plan: Transportation; Telecommunications; Agriculture and Agri-food; Public Health and Essential Health Services; Environment; Law Enforcement; Logistics Operations Management; Communications; and Border Services.

The Department and the Canadian Coast Guard are also identified as core group partners under the Maritime Event Response Protocol: an annex to the Federal Emergency Response Plan. Furthermore, Fisheries and Oceans Canada is also identified as a co-lead department for two (2) of the thirty-seven (37) nuclear emergency functions identified in the Federal Nuclear Emergency Plan as well as a supporting department for eight (8).

The Department's responsibilities as a supporting department are defined in the Fisheries and Oceans Canada Strategic Emergency Management Plan: an overarching strategic plan that outlines the Department’s (all sectors/regions including the Canadian Coast Guard) comprehensive and coordinated approach to emergency management at a departmental level. As this Plan is a high level document, the roles and responsibilities of the regions for both the Department and the Canadian Coast Guard are not defined. Since emergencies tend to be local in nature involving municipal and provincial actions, it is often the regions that will be called upon to provide assistance during an emergency. Furthermore, although the Plan has been approved and finalized, it has not been extensively circulated across the Department. Consequently, the Safety, Security and Emergency Services staff in the regions are not clear as to what is required from them and interviews revealed that some regions do not fully understand the scope of their respective regional roles and responsibilities pertaining to emergency preparedness under the Federal Emergency Response Plan.

Currently, each of the Canadian Coast Guard’s three (3) Regional Operations Centres has regional Fleet Readiness Response Profiles, which outline the protocols for their emergency responses. For the Safety, Security, and Emergency Services Branch, only the Quebec, Gulf, and Maritimes regions have developed a regional emergency management plan to outline their approach and structure for responding to emergencies. The regional Safety, Security and Emergency Services group of the Central and Arctic Region, however, indicated that regional plans are not required as the Department’s supporting role is documented under the Federal Emergency Response Plan. The remaining regions (Pacific and Newfoundland and Labrador) have not developed emergency management plans and are waiting for national guidance before proceeding further. 

Interviews also revealed that the role of Safety, Security, and Emergency Services is not clear. The Strategic Emergency Management Plan does not clearly define who has primary responsibility for coordinating a response within the Department. While interviews revealed that for emergencies requiring the Canadian Coast Guard’s participation, they would be responsible for coordinating the response within their organization; however, for emergencies requiring action by Fisheries and Oceans Canada, responsibilities for coordination have not been defined and are not well understood. In addition, during an emergency requiring a joint Canadian Coast Guard and Fisheries and Oceans response, protocols for establishing a lead coordinator have not been developed.

In light of the above, the audit has identified an opportunity to clarify and communicate the roles and responsibilities of the various stakeholders including documenting responsibility for providing leadership in the coordination of an emergency response.

Recommendations / Management Action Plan
Recommendation Management Action Plan
R- 1. The Assistant Deputy Minister, Human Resources and Corporate Services, should ensure that the roles and responsibilities for emergency preparedness at the operational level are clearly defined and communicated across all sectors and regions of the Department, as well as the Canadian Coast Guard.
  1. As Human Resources and Corporate Services (HRCS) completes the ongoing review of the Strategic Emergency Management Plan, it will ensure that roles and responsibilities for emergency preparedness at all levels, including the operational level are clearly defined. In doing so, Human Resources and Corporate Services will ensure that these roles and responsibilities are broadly consulted amongst the members of the Strategic Emergency Management Plan Working Group and that the newly created Safety, Security and Emergency Management Oversight Committee consider and approve the Strategic Emergency Management Plan thus ensuring a strategic senior management oversight of these roles and responsibilities.
  2. A communications plan will be developed to ensure that all stakeholders, including the Canadian Coast Guard, sectors and the regions, receive a copy of the approved Strategic Emergency Management Plan and are made aware of their roles and responsibilities at all levels throughout the organization.
Office of Primary Interest: Human Resources and Corporate Services
Due Date: 1. January 30, 2015
2. February 27, 2015

6.2 COORDINATION OF EMERGENCY RESPONSE

The Emergency Management Act sets out the roles that all stakeholders must play in Canada’s emergency management system including those of Public Safety Canada and other government institutions. Public Safety Canada maintains a network of partnerships with other federal government institutions, provincial and territorial emergency management organizations and is responsible for coordinating the Government of Canada’s response to an emergency. To facilitate an integrated Government of Canada response, Public Safety Canada developed the Federal Emergency Response Plan in consultation with other federal government institutions. It is designed to harmonize the federal emergency response with those of the provincial/territorial governments, non-governmental organizations, and the private sector.

According to the Federal Emergency Response Plan, federal government institutions may have multiple roles:

  • In the governance structure;
  • At the regional level;
  • Through the Federal Coordination Group;
  • In a response role through the Emergency Support Functions; and
  • In augmenting the Government Operations Centre, through federal departmental representatives.

The Federal Emergency Response Plan was developed to ensure that the Government of Canada response is coordinated to maximize the use of all available resources in the most timely and effective way possible. Given the need for a coordinated response at a government-wide level, there is also an expectation that individual federal government institutions are structured appropriately to ensure their activities are coordinated internally to ensure all resources are ready to support the Government of Canada response.

Observations Section 6.2
Observations
Low 6.2.1 While mechanisms are in place to ensure the effective coordination and response between the department and external stakeholders, there is a lack of formal internal communication and coordination mechanisms to ensure a harmonized response that maximizes situational awareness and the use of available resources within the Department and the Canadian Coast Guard.

Effective communication and coordination are essential ingredients for emergency response management. The coordination of an emergency response is challenging in that emergencies vary greatly in nature, include high uncertainty and require quick decisions based on limited information for immediate action. Emergencies often involve multiple jurisdictions; municipal, provincial/territorial, and federal governments, as well as other non-government organizations with specialized or general response capabilities. To ensure better planning, coordination, and incident management across jurisdictions, sectors, and among all federal institutions, Public Safety developed the Federal Emergency Response Plan and the Federal Policy for Emergency Management in 2009 following the coming into force of the Emergency Management Act in 2007. The Federal Emergency Response Plan outlines the mechanisms and processes to facilitate an integrated Government of Canada response to an emergency. In 2007, the federal, provincial, and territorial governments joined efforts to produce An Emergency Management Framework for Canada, which establishes a common approach for the various government emergency management initiatives. The Framework aims to enable consolidation of multi-governmental collaborative work and ensure more coherent, complementary actions among the different governmental initiatives.

As all ministers are responsible for preparing emergency management plans in respect of the risks that are within or related to his or her area of responsibility, Fisheries and Oceans Canada developed its Strategic Emergency Management Plan, thereby outlining the Department’s comprehensive and coordinated approach to emergency management at a departmental level. This plan was developed to ensure that the Department is able to fulfill its emergency management duties and to ensure a coordinated emergency response to situations for which federal assistance has been requested. The plan provides details on the various information coordination and operations centres established within the Department. It also identifies and describes the internal structure for emergency management within the Department and the Canadian Coast Guard.

organisational chart

The figure above shows the two separate lines of communication between Fisheries and Oceans Canada and Public Safety Canada’s Government Operations Centre, the monitoring and coordination centre for the federal response to an emergency event. One line is linked to the Fisheries and Oceans Canada National Emergency Information Centre, which is managed by the Safety, Security, and Emergency Services branch, and the other is linked to the Canadian Coast Guard National Coordination Centre, which is linked to the Canadian Coast Guard’s Regional Operations Centres, Joint Rescue Coordination Centres, and Marine Security Operation Centres. Although the Strategic Emergency Management Plan illustrates the communication between the Canadian Coast Guard and Public Safety and between the Safety, Security, and Emergency Services branch and Public Safety, the communication within the Department between Safety, Security, and Emergency Services and the Canadian Coast Guard is not described. The audit also found that there is no formal protocol in place for communication between the National Emergency Information Centre and the National Coordination Centre. In addition, the structure is not conducive to allow for the coordination of joint emergency preparedness activities since the two centres operate independently from one another.

Although there may not always be a need to inform each other, both entities have expressed that, at various times, they each have not been adequately informed accordingly by the other. While there may be a need to have two separate communication lines with Public Safety due to the different mandates of the Canadian Coast Guard and the Department, in some types of emergencies, exercises (e.g., under the Federal Nuclear Emergency Plan), and training (e.g., pertaining to the Incident Command System), it may be necessary for the National Coordination Centre and the National Emergency Information Centre to better communicate and coordinate with each other in order to ensure an increased situational awareness and an effective, timely response.

Interviews with regional Emergency Services staff revealed that there is also a communication gap between the Canadian Coast Guard and Emergency Services in some regions or Canadian Coast Guard zones. Since emergencies are more likely to occur in a region, the Safety, Security, and Emergency Services branch and the Canadian Coast Guard in the regions/zones would be responsible for directing operations and taking action during an emergency; communication of information to ensure increased situational awareness and coordination of resources and operations at this level are particularly important for an effective departmental emergency response.

Moreover, while the Canadian Coast Guard is establishing its National Situation Centre, there is an opportunity to revisit the internal structure to determine options for representation from Safety, Security, and Emergency Services and sectors/regions. As the National Coordination Centre is going to be relocated within the National Situation Centre, there are options with respect to how the Situation Centre can facilitate coordination between the Coast Guard’s National Coordination Centre and Safety, Security, and Emergency Services branch’s National Emergency Information Centre.

The Department may also refer to the models that Health Canada and Agriculture and Agri-Food Canada use within their respective internal organizations to coordinate a joint response. Health Canada and the Public Health Agency of Canada have one operations centre, a Portfolio Operations Centre, which is managed by the Public Health Agency of Canada. Information and requests for assistance from Public Safety’s Government Operations Centre are received at the Portfolio Operations Centre, and depending on the type of request, the Public Health Agency of Canada and Health Canada decide which organization should respond. Agriculture and Agri-Food Canada and the Canadian Food Inspection Agency also share one operations centre, their Emergency Operations Centre; however, they each have their own line of communication with Public Safety Canada similar to Fisheries and Oceans Canada and the Canadian Coast Guard. Because the Canadian Food Inspection Agency’s mandate pertains to enforcement, the vast majority of the responses are led by the agency. Thus, the Emergency Operations Centre is largely manned by the Canadian Food Inspection Agency while there is one Agriculture and Agri-Food Canada representative.

While emergency management continues to evolve at Fisheries and Oceans Canada, there are currently no formalized protocols for communication between the Canadian Coast Guard and the Safety, Security, and Emergency Services branch at National Headquarters and in the regions. Thus, there is an opportunity to develop, in support of the emergency management plans, clearer expressions of roles and responsibilities between Safety, Security, and Emergency Services and the Canadian Coast Guard, as well as protocols and operating procedures to clarify how and under what circumstances a response is coordinated, information is shared, and senior management is informed.
Recommendations / Management Action Plan
Recommendation Management Action Plan

R-2. The Assistant Deputy Minister, Human Resources and Corporate Services in collaboration with the Deputy Commissioner, Operations, Canadian Coast Guard, should review the current structure to identify opportunities for better integration, coordination and communication between the Canadian Coast Guard and Fisheries and Oceans both at National Headquarters and in the regions.

The communication process between the National Emergency Information Centre and the National Coordination Centre will be formalized and a communication structure will be jointly developed. The Safety, Security and Emergency Management Oversight Committee will be involved in both the development and approval process.

This communication process will be developed as an Annex to the Strategic Emergency Management Plan.

Office of Primary Interest: Human Resources and Corporate Services
Due Date: September 30, 2015

6.3 STATE OF PREPAREDNESS

The emergency management responsibilities of the Minister of Fisheries and Oceans Canada, who is accountable to Parliament under the Emergency Management Act, are to:

  • Identify the risks that are within or related to his/her area of responsibility, including those related to critical infrastructure;
  • Prepare emergency management plans in respect of those risks;
  • Maintain, test, and implement those plans; and
  • Conduct exercises and training in relation to those plans.

Emergency preparedness encompasses the measures and planning activities to ensure a government institution is ready to respond quickly and effectively to an emergency and manage its consequences through measures taken prior to an emergency event. These measures and activities include developing emergency management plans that are aligned with the Federal Emergency Response Plan, establishing protocols for coordination and communication that clearly outline roles and responsibilities for sharing information, decision-making, and briefing senior management. Protocols are program and topic-specific documents which provide direction on how entities must operationalize specific requirements identified within the Strategic Emergency Management Plan. Protocols are also an important mechanism by which greater standardization is achieved in the department-wide implementation of emergency management programs. The purpose of a protocol can be to provide direction regarding the implementation of measures that will prepare the Department to respond to emergencies.

Public Safety Canada recommends that government institutions adopt an all-hazards approach to implement the necessary activities aimed at building, sustaining, and continually improving their capability to respond effectively to large-scale emergencies and to reduce the potential of loss of life and personal injuries. In addition, Public Safety Canada supports the implementation of an Incident Command System, which, according to the United States Centre for Excellence in Disaster Management and Humanitarian Assistance, is a set of personnel, policies, procedures, facilities, and equipment, integrated into a common organizational structure designed to improve emergency response operations of all types and complexities. The Canadian Coast Guard is leading the implementation of the Incident Command System with Fisheries and Oceans Canada.

Observations Section 6.3
Observations
Moderate 6.3.1 The Department's state of preparedness cannot be fully assessed as emergency management continues to evolve within the Department, many of the existing emergency management components are being adapted to re-align with the evolving government-wide approach to emergency management.

The Federal Emergency Response Plan and other guiding documents developed by Public Safety Canada and the Treasury Board Secretariat provide a framework for coordinating emergency preparedness activities, including the establishment of a governance structure and other measures for departments to fulfil their role during an emergency. To ensure consistent delivery of emergency preparedness activities across the Department, the Strategic Emergency Management Plan was developed as a corresponding framework document for Fisheries and Oceans Canada.

Due to its mandate related to maritime safety and security, the Canadian Coast Guard has established national frameworks, protocols, plans, and systems that outline their emergency response as well as mechanisms to assess their state of preparedness on an ongoing basis. Furthermore, to improve the Canadian Coast Guard’s ability to manage responses to marine and all-hazard emergency incidents in collaboration with key emergency response partners, the Canadian Coast Guard is currently establishing an internationally recognized Incident Command System, which is a standard emergency management system for the command, control and coordination of emergency response operations. One of the priority components of Incident Command System implementation will be the establishment of the Canadian Coast Guard National Situation Centre, within which the National Coordination Centre will be relocated. Also, as previously mentioned, each of the Canadian Coast Guard’s three (3) Regional Operations Centres has regional Fleet Readiness Response Profiles, which outline the protocols for their emergency responses. Thus, the Canadian Coast Guard has established the resources, capacity, and capabilities to respond to an emergency situation and is well-prepared to do so as proven through recent events, for example, the Canadian Coast Guard’s handling of the drifting Russian cargo vessel in British Columbia in 2014, as well as how it activated its Headquarters Fleet Emergency Management Plan to respond to the crash of one of its helicopters in the Arctic in 2013.

In its work to advance emergency management within the Department and to ensure alignment with the Federal Emergency Management Plan, Safety, Security, and Emergency Services has finalized the departmental Strategic Emergency Management Plan and is currently refining it to reflect recent changes such as changes to the Departmental governance structure as well as changes to the governance structure for emergency management. However, some of the corresponding protocols, processes, and procedures are still in development as are some of the related plans for testing, training, and exercises. In addition, mechanisms for assessing and monitoring the Department’s state of preparedness have not been developed. As these mechanisms are being developed, Safety, Security, and Emergency Services has an opportunity to benefit from the Canadian Coast Guard’s expertise and well-established emergency management system. Nonetheless, the Safety, Security, and Emergency Services staff in some of the regions have developed regional emergency management plans and have participated in emergency-related exercises. While emergency management within Fisheries and Oceans Canada is evolving, the Safety, Security, and Emergency Services directorate has demonstrated its ability to prepare for, and respond to, emergency situations, such as annual flooding incidents in the Maritimes and Central and Arctic regions.

In light of the above, the Department has demonstrated its capacity to respond to emergency situations notwithstanding the fact that emergency management is still relatively new across the federal government and there has been insufficient guidance or direction from Public Safety Canada and Treasury Board regarding emergency preparedness.

Recommendations / Management Action Plan
Recommendation Management Action Plan

R-3. The Assistant Deputy Minister, Human Resources and Corporate Services should:

  • Operationalize the Strategic Emergency Management Plan, including the development of protocols, processes, and regional emergency management plans;
  • Conduct joint exercises to validate and test the governance structure and the concept of operations presented in the Strategic Emergency Management Plan and its corresponding operational plans, as appropriate;
  • Consider establishing a monitoring mechanism for emergency preparedness activities once implemented to ensure the Department’s compliance with relevant legislations and policies.
  1. To strengthen relationship and provide a solid foundation for the implementation of the following activities, the Strategic Emergency Management Plan Working Group will be redefined in order to establish a broader Safety, Security and Emergency Management Working Group across all sectors of the Department, and the Canadian Coast Guard.
  2. Human Resources and Corporate Services, in consultation with the Strategic Emergency Management Plan Working Group, will identify the protocols, processes and regional emergency management plans which need to be developed and approved in order to operationalize the Strategic Emergency Management Plan. Advice and guidance will also be provided to regional Safety and Security staff as well as management to assist them with the development of required protocols, processes and plans.
  3. Human Resources and Corporate Services will coordinate and conduct a table-top exercise for the Deputy’s Management Committee next retreat in order to test the governance structure and the concept of operations presented in the Strategic Emergency Management Plan. Guidance and support will also be provided to regional Safety and Security staff as well as management to assist them in conducting joint exercises to test their respective plans.
  4. As part of the Safety, Security and Emergency Management Comprehensive Review, Human Resources and Corporate Services will conduct a gap analysis, the results of which will inform the development of monitoring mechanisms for emergency preparedness activities. These mechanisms will be developed in consultation with the Canadian Coast Guard, other sectors and regions.
Office of Primary Interest: Human Resources and Corporate Services
Due Date:
  1. January 30, 2015
  2. October 31, 2015
  3. By March 31, 2015 for table-top exercise at DMC; and by December 31, 2015 for regional guidance/support
  4. March 31, 2016

7.0 AUDIT OPINION

Based on the audit findings, our opinion is that, while the Department has demonstrated its capacity to respond to an emergency, the audit revealed opportunities for improvement in terms of formalizing and refining the internal structures, processes, and controls in order to ensure a more coordinated and efficient departmental response. Specifically, improvements should be made to clarify roles and responsibilities and to ensure a more unified departmental approach to emergency preparedness in an effort to improve its capability to respond to emergency events in a more efficient and effective manner. The recommended improvements are as follows:

  • Ensure that the roles and responsibilities for emergency preparedness at the operational level are clearly defined and communicated across all sectors and regions of the Department, as well as the Canadian Coast Guard.
  • Review the current structure to identify opportunities for better integration, coordination and communication between the Canadian Coast Guard and Fisheries and Oceans Canada both at National Headquarters and in the regions;
  • Operationalize the Strategic Emergency Management Plan, including the development of protocols, processes, and regional emergency management plans;
  • Conduct joint exercises to validate and test the governance structure and the concept of operations presented in the Strategic Emergency Management Plan and its corresponding operational plans, as appropriate; and
  • Consider establishing a monitoring mechanism for emergency preparedness activities once implemented to ensure the Department’s continued compliance with relevant legislations and policies.

8.0 STATEMENT OF CONFORMANCE

In my professional judgment as Chief Audit Executive, sufficient and appropriate audit procedures have been conducted and evidence gathered to support the accuracy of the opinion provided and contained in this report. The extent of the examination was planned to provide a reasonable level of assurance with respect to the audit criteria. The opinion is based on a comparison of the conditions, as they existed at the time, against pre-established audit criteria that were agreed on with Management. The opinion is applicable only to the entity examined and within the scope described herein. The evidence was gathered in compliance with the Treasury Board Policy and Directive on Internal Audit. The audit conforms to the Internal Auditing Standards for the Government of Canada, as supported by the results of the Quality Assurance and Improvement Program (QAIP). The procedures used meet the professional standards of the Institute of Internal Auditors. The evidence gathered was sufficient to provide Senior Management with proof of the opinion derived from the internal audit.

APPENDIX A – AUDIT CRITERIA

Based on a combination of the evidence gathered through documentation examination, analysis and interviews, each of the audit criteria listed below was assessed and a conclusion for the audit criteria was determined using the following definitions:

Conclusion per Audit
  Conclusion on Audit Criteria Definition of Opinion
1 Criteria Met – Well Controlled Well managed or no material weaknesses noted, controls are effective.
2 Criteria Met with Exceptions – Controlled Requires minor improvements.
3 Criteria Met with Exceptions – Moderate Issues Requires improvements in the areas of material financial adjustments, some risk exposure.
4 Criteria Not Met – High Impact – Significant Improvements Requires significant improvements in the area of material financial adjustments, serious risk exposure.

The following are the audit criteria and examples of key evidence and/or observations noted which were analyzed and against which conclusions were drawn.  In cases where significant improvements and/or moderate issues were observed, these were reported in the audit report.

Audit Criteria / Conclusions
Audit Criteria Conclusion on Audit Criteria Examples of Key Evidence/ Observations
Line of Enquiry 1 – Governance and Strategic Direction
Criterion 1.1:  Governance mechanisms are in place to provide clear direction and oversight for emergency preparedness activities. 2 6.1.1
Criterion 1.2:  Accountabilities, roles, and responsibilities of key internal stakeholders involved in emergency preparedness activities are clearly defined, communicated, and understood. 2 6.1.1
Criterion 1.3:  Operational plans and resource strategies are in place to support the implementation of emergency preparedness activities. 3 6.3.1
Line of Enquiry 2 – Emergency Preparedness Activities
Criterion 2.1:  An adequate emergency management framework is in place to provide guidance in the development and implementation of emergency management plans across the Department. 3 6.3.1
Criterion 2.2:  Emergency preparedness activities are carried out using an all-hazard, risk-based approach. 3 6.3.1
Criterion 2.3:  Adequate emergency management plans are in place and communicated. 3 6.3.1
Line of Enquiry 3 – Monitoring and Reporting
Criterion 3.1:  Emergency preparedness activities are monitored consistently across the Department and reported on an on-going basis. 3 6.3.1
Criterion 3.2:  Mechanisms are in place to monitor compliance of emergency preparedness activities with relevant legislations and policies and to ensure adjustments are made accordingly. 3 6.3.1
Line of Enquiry 4 – Partnerships and Collaboration
Criterion 4.1:  Partnerships and collaboration with key external stakeholders are formalized and communicated. 1 6.1.1
Criterion 4.2:  Mechanisms are in place to ensure effective coordination and response between the Department and the key external stakeholders in the event of an emergency. 2 6.1.1
6.2.1