July 2004

Audit and Evaluation Branch

This Audit and Evaluation Branch project was completed by Jacques Whitford Environment Limited under contract with the direction of Stella Line Cousineau; they would like to thank those individuals who contributed to this project.

Executive Summary

Recent changes to the Canada Labour Code have alerted senior management to their need to demonstrate due diligence as it pertains to the safety and health of departmental employees. As a result, Jacques Whitford Environment Limited (JWEL) was retained by the Audit and Evaluation (AEB) Branch of Environment Canada to conduct an audit of the Canada Labour Code Part II requirements for Occupational Safety and Health at Environmental Protection Service.  The scope of the audit included the Wastewater Technology Centre (WTC), the Environmental Technology Centre (ETC) and two National Air Pollution Surveillance stations (NAPS).  A questionnaire was developed from a review of CLC Part II combined with Risk Elements and Criteria provided by the Audit and Evaluation Branch of Environment Canada.  The audit also included a walk through review of the facilities at the Environmental Technology Centre and NAPS Stations inOttawa, and the Wastewater Technology Centre in Burlington.

The need for this audit was brought forth during the consultation phase of the 2002-2005 Audit and Evaluation Plan and was approved by the Departmental Audit and Evaluation Committee (DAEC).  More specifically, the purpose of this audit was to determine whether the operations at the EPS centres were carried out in a way that meets the due diligence with regards to the occupational safety and health requirements of the Canada Labour Code part II.  The focus of the audit was on section 125 and 135 of the CLC and any other sections of the Code deemed appropriate by the consultant. 

Findings

Safety is clearly considered important within EPS facilities.  The high standards of engineering in the labs at the facilities are evidence of this. Senior managers discuss safety within their meetings, as does the Joint Occupational Safety and Health (JOSH) committee that meets regularly and is supported by senior management.  All employees who were interviewed had a very positive attitude towards safety.  Safety is discussed at the various departmental meetings and ETC has developed a safety Local Area Network.  The evaluation of the Workplace Hazardous Material Information System (WHMIS) program indicated that labelling is generally good with a few exceptions.  These exceptions should be identified as part of the regular inspection process.

The CLC Part II regulations are new and the questionnaire developed from the Audit and Evaluation Branch criteria is very detailed.  As a result this audit could be viewed as a GAP analysis between existing programs and the requirements of the new regulations.  In this way it can be used as a road map to further enhancing the existing program.

Specifically the audit found:

1. OSH Management System:  As evidenced through a lack of complete documentation, many of the safety programs are not formalized.  In order for existing health and safety processes to be sustainable they should be included into an OSH management framework to ensure for instance that they continue independently of individual efforts. The use of an OSH management system at all locations would also enable consistent demonstration of both management commitment to safety and ability to show ‘Due Diligence’ in the event of an incident.
   
2. Employee Involvement /OSH Objectives:  Based on the results of the interviews, all employees knew of the safety intent of the organization but active involvement mainly lay with the members of the JOSH committee.  The safety program would be strengthened by the chain of command having the leading role in the safety program and the JOSH having a monitoring role.  Management use of formal OSH objectives and targets (such as injury rates, completion of corrective actions, and updating of safe work procedures) accompanied by performance indicators would allow better tracking and support of the safety program.
   
3. Risk / Hazard Analysis:  Based on the review of the safety program, (as distinct from the environmental management system) the audit team was unable to find evidence of formal risk and hazard analysis for some of the routine activities such as acid transfer, hot work, line breaking, confined space entry etc., performed at the centres.  Currently, the supervisors ensure that tasks are done correctly and that procedures represent the best and safest method.  Identifying critical tasks is a mean for management to ensure appropriate measures are taken.
   
4. Training:  While the centres do plan to complete CLC Part II training, a training needs analysis for employees should be instituted.  This could then be used to set up a routine refresher safety training program.
   
5. Chemical Receiving:  Based on the results of the interview, the audit team found that substances can be distributed into the workplace without the needed checks being completed.  All locations should re-visit the receipt of all substances to ensure compliance with the WHMIS regulation and the CEPA New Substances regulation.
   
6. Emergency Response Planning:  Emergency Preparedness Plans (EPP) are either in place or are being upgraded. Although fire drills have taken place regularly at the sites, there have been no drills or training on other relevant emergency scenarios (i.e. spill response, explosions, severe weather, worker rescue, bomb threats, etc.).
   
7. Security:  The WTC facility has a visitor access process but it is not foolproof as it is possible to bypass the guard. In the event of an incident, it currently may be difficult to account for all visitors.
   
8. NAPS Sites:  The NAPS sites were visited.  The key findings were the need for a Working Alone Policy to be developed for the contractor who accesses the sites weekly, and for permanent wiring to be installed to limit the use of extension cords and power bars.

Detailed findings and recommendations are under Section 2.0.