Internal Audit and Program Evaluation Directorate
Audit of Occupational Health and Safety
March 2019

1.0 Introduction

1. The Canada Border Services Agency (CBSA) provides integrated border services that support national security, protect public safety, and promote Canada’s economic prosperity through its core targeting, examination, detection and enforcement activities. In collaboration with Public Safety partners, the Agency operates in a complex and dynamic environment, keeping pace with constantly evolving cross-border criminal activity, national security threats, migration flows, and public safety priorities to intervene threats at the earliest possible point in the travel and trade continuum^{Footnote 1}.

2. The Agency is responsible for and committed to providing a safe working environment for all of its employees^{Footnote 2}. Promotion of safe working conditions and compliance to regulations are key components of health and safety in the workplace. The Canada Labour Code (CLC) - Part II and its related regulations establish the legislative framework and form the basis of the CBSA OHS mandate to promote a safe and healthy workplace and to reduce the incidence of occupational injuries and illnesses.

3. The CBSA carries out its responsibilities with a workforce of approximately 15,185 employees, including over 10,300 operational officers^{Footnote 3} who provide services at approximately 950 points of service across Canada and at 39 international locations^{Footnote 4}. The Occupational Health and Safety (OHS) section’s annual operating budget is $18,000 and is staffed with three national advisors and a director.^{Footnote 5} They are supported by eight regional OHS advisors.^{Footnote 6} The Agency has 266 workplaces across Canada, of which there are 101 OHS workplace committees and 165 OHS workplace representatives.

2.0 Significance of the audit

4. The Agency must ensure that it is taking a responsible approach to reduce, prevent or eliminate workplace hazards through monitoring and evaluating the programs and practices in place to protect the health and safety of its employees.

5. While approximately 32% of the Agency’s employees work in what may be characterized as a conventional office environment with a relatively low degree of inherent risk, about 68% work in an environment that has elevated levels of risk to their health and safety. The Agency’s operational officers may work in isolated locations, encounter aggressive travellers, and travel overseas on escorted removals. Officers working on the inspection and examination of goods and travellers risk encounters with highly toxic substances and other chemicals, dangerous goods and potentially hostile individuals, and the unknown risk factors that exist in the work environment. Additionally, some frontline officers work in ports of entry that were built years ago and aging infrastructure may present hazards to health and safety.

6. The audit objective was to provide assurance that the Agency has effective controls and practices in place to support its OHS program and to ensure compliance with legal requirements of the CLC Part II and related regulations.

7. The audit scope included an assessment of the governance, management and oversight of the OHS program; risk management practices in place at selected ports of entry (POEs) and Agency workplaces; and key business practices of stakeholders with OHS responsibilities in managing workplace hazards and risks. During the examination phase, the audit team visited 23 work sites across Canada.

8. The detailed audit methodology, scope and criteria are described in Appendix A. The workplaces visited are included in Appendix B.

3.0 Statement of conformance

9. This audit was conducted in conformance with the Treasury Board Policy and Directive on Internal Audit and the Institute of Internal Auditors’ (IIA) International Professional Practices Framework (IPPF). Sufficient and appropriate evidence was gathered through various procedures to provide an audit level of assurance. The Agency’s internal audit function is independent and internal auditors performed their work with objectivity as defined by the IIA’s International Standards for the Processional Practice of Internal Auditing.

4.0 Audit opinion

10. Overall, the Agency has a functioning OHS program with defined controls in place to support the delivery of OHS in the regions. Opportunities exist to clarify and communicate roles and responsibilities, and ensure required training is completed. Additionally, there are opportunities to clarify and communicate requirements for recording workplace activities, and strengthen the hazard prevention program as well as monitoring and reporting activities. Improvements in these areas will strengthen the prevention of hazards and ensure the health and safety of employees is protected.

5.0 Key findings

11. Roles and responsibilities of key OHS stakeholders were defined and documented. Clarity could be provided with respect to the monitoring responsibilities of regional OHS advisors and recording procedures for workplace health and safety activities for committee members and representatives. Procedures, processes and guidance were in place to help key stakeholders perform their OHS duties. However, management should ensure that workplace committee members and representatives complete their required training.

12. Workplace committees have been established and representatives are appointed at workplaces where there is less than 20 employees to ensure that hazards are identified, investigated, and addressed. Hazardous Occurrence Investigation Reports were prepared as per requirements, included corrective actions to address hazards, and followed the established approval process. However, not all required workplace committee meetings and workplace inspections took place in 2016 and 2017.

13. Quarterly reports with committee activities and hazardous occurrences information were prepared at the workplace, regional and national levels, however discrepancies in the number of inspections and number of occurrences were noted in the reports examined. Limited monitoring activities were performed to ensure that compliance with legislative requirements was met and that the number of hazards and injuries was consistently and accurately reported.

14. The Agency has a formal Hazard Prevention Program (HPP) to identify and assess hazards in the workplace and an associated implementation plan was approved in 2018. With respect to the implementation plan, an issue of particular importance is the outstanding work related to Job Hazard Analyses (JHA). While the HPP Implementation Plan is a standing item on the Policy Health and Safety Committee (PHSC) agenda, there is limited evidence to demonstrate the committee’s involvement in the prioritization of activities and the monitoring of timelines to ensure the required JHA are conducted as planned.

6.0 Summary of recommendations

15. The audit makes four recommendations relating to:

• Developing a process to identify those who require training and ensuring the required training is completed;
• Clarifying and communicating roles and responsibilities for key OHS stakeholders, and the expectations related to the process for documenting and recording workplace health and safety committee meetings and workplace inspections;
• Ensuring that OHS performance information, including compliance with legislative requirements, is consistently recorded, analysed for accuracy and trends, monitored and reported to an oversight committee; and
• Strengthening the prevention of hazards by establishing implementation timelines, prioritizing job hazard analyses of occupations with the greatest exposure to hazards, and monitoring the progress of the implementation plan.

7.0 Management response

8.0 Audit findings

8.1 Accountability and Responsibilities

OHS Program Accountability

16. Under the CLC Part II, occupational health and safety is a shared responsibility of the employer and employee. The Agency’s OHS program falls under the Human Resources Branch (HRB) and the Labour Relations and Compensation Directorate (LRCD) is the OHS functional authority. As such, it develops, implements and monitors the OHS program and provides advice and guidance to the rest of the Agency on the legislative requirements, policies and procedures.

17. The National OHS section developed an OHS Framework that outlines the specific roles and responsibilities of the various OHS stakeholders. Roles and responsibilities for National and Regional OHS Advisors, workplace committee members and representatives, Policy Health and Safety Committee (PHSC) and management are defined and documented in this Framework to ensure that effective management of health and safety is maintained at every workplace and that an employee-employer partnership is in place to prevent accidents and injury to health arising out of, linked with or occurring in the course of employment. These include roles and responsibilities for policy, training, guidance, monitoring, reporting and on the development and maintenance of the HPP. See Appendix C for CBSA OHS roles and responsibilities.

Occupational Health and Safety Advisors

18. The National OHS section and its national advisors develop policies and procedures and collect information on the OHS program. In addition to providing support to regional advisors, national advisors have a role in monitoring health and safety activities and preparing reports for the OHS section. Regional advisors provide OHS-related guidance and direction to management, workplace committee members and representatives in their respective region. They are also responsible for monitoring workplace health and safety committees’ activities, identifying and coordinating OHS training and compiling statistical information for the National advisors. Regional advisors are not fully dedicated to OHS; they also are regional labour relations advisors.

19. Although regional OHS advisors assist in coordinating and providing OHS training, not all of them tracked whether workplace committee members had completed the required OHS training. Similarly, while the OHS Framework states that the Regional Advisors are also expected to monitor the performance of workplace committees and representatives, including the review of meeting minutes and inspection reports, not all regional advisors conducted the same extent of review or monitoring of workplace committee activities. To support management, workplace committee members and representatives, it is important that OHS regional advisors understand their roles and responsibilities.

20. At the time of this report, regional advisors reported to regional Human Resource Directors within the Operations Branch, who report to Regional Directors General (RDGs). The Agency is undergoing a period of transformation, which looks at re-aligning some areas of the Agency. The CBSA’s senior management announced its intention to nationalize internal services, including OHS, to enhance controls, consistency, accountability and ability to share workload. In implementing its Renewal initiatives, the Agency has an opportunity to clarify the roles and responsibilities of the regional OHS advisors, explore the options of having fully dedicated OHS resources and define clear and direct functional reporting relationships for OHS.

Workplace Committees and Representatives

21. As per the CLC Part II^{Footnote 7}, a workplace health and safety committee should consist of employee and employer representatives established at all work locations where twenty or more employees are normally employed. Health and safety representatives shall be appointed at work locations where less than twenty employees are normally employed. Workplace committee members and representatives have specific duties under the CLC.

22. Although most workplace committee members and representatives expressed being aware of their roles and responsibilities, some did not fully understand the extent of their accountabilities in certain health and safety processes in the workplace such as recording internal complaints and work refusals, and recording injuries and incidents that occur during re-certification of skills at training facilities. Since internal complaints and work refusals occur infrequently, workplace committee members were not clear on how to document and process them. They often needed to refer to regional advisors for guidance in order to investigate and participate in these processes.

23. A lack of understanding or awareness of roles and responsibilities could lead to unperformed tasks and activities. Therefore, an opportunity exists to clarify roles, responsibilities and expectations of workplace committee members or representatives.

8.2  Procedures, Processes and Guidance

24. According to the CLC Part II^{Footnote 8}, the Agency must post a statement of the employer’s general policy concerning the health and safety at the workplace supporting the employees.

25. The CBSA has an overarching OHS policy as well as other policies and procedures. It commits the Agency “to protecting the health and safety of its employees at the workplace by complying with all health and safety legislative requirements, approved standards, directives and policies, and by ensuring that employees have the necessary equipment, training, instruction and supervision to safely carry out their duties on behalf of the CBSA”^{Footnote 9}. These policies and procedures are available on the Agency’s Intranet.

26. The Agency’s policies and procedures were developed by the National OHS Section. OHS procedures and processes, such as First Aid procedures, the work refusal and internal complaint resolution processes, are available to support employees and managers in performing their OHS duties. As well, tools, templates and forms are available on the Intranet.

27. In addition to the policies, procedures, and tools, a network of national and regional OHS advisors is established to support the workplace committee members and representatives by providing advice and feedback and by responding to questions and concerns. National advisors inform the regional advisors of changes in procedures, and they in turn communicate the information to their respective workplace committees and representatives, and others, as needed.

28. While the policies, directives and guidance were established and available, 70% of workplace committee employee members and 58%^{Footnote 10} of workplace committee employer members interviewed were not aware of available OHS procedures and guidance on the Intranet. The majority indicated that they had learned processes and responsibilities related to OHS via on-the-job training. Additional communication and training would provide more information regarding available tools and templates to help them discharge their responsibilities and help drive a consistent application of processes and controls.

Training

29. The Training and Development Directorate (TDD), in collaboration with the National OHS section, developed a suite of OHS training courses for employees at all levels. Courses specifically designed to improve their OHS-related knowledge and skills and provide the necessary guidance in carrying out their OHS duties are required for employees, managers, workplace committee members and representatives. Mandatory OHS training provides all CBSA employees with an understanding of their rights and obligations, as well as those of the employer, under the CLC Part II.

30. Managers, supervisors, workplace committee members and representatives must complete required OHS online training followed by an in-class training session. Due to their duties, they require an in-depth understanding of OHS concepts and procedures. The OHS in-class session is important as it provides participants with the opportunity to apply OHS knowledge, skills and best practices acquired in the online training. Regional OHS advisors are responsible for tracking completion of the required OHS training.

31. The audit team sought to confirm OHS training completion rates for employees with key OHS responsibilities, but encountered an issue. Lists of workplace committee members and representatives are kept current at the local and regional levels, but there is no regular roll-up prepared by the OHS section. Quarterly training statistics are provided by TDD to the OHS section and reported to the PHSC based on an outdated membership list.

32. In the absence of fulsome data on training, a sample of workplace committee members and representatives was tested against training completion reports received from TDD.

33. The audit found that some individuals from the sample did not appear on the report and some appeared as not having completed the training. From the audit sample, 68% of workplace committee members and representatives had completed the online portion of the OHS training. Of the 73 workplace committee members and representatives interviewed, 59% had completed the in-class OHS training.

34. Interviewees provided several reasons as to why training was not completed, which included infrequent in-class training offering due to trainer and resource availability, and cancelled classes due to low registration numbers. Another reason had to do with the availability of resources to backfill officers while on training. Over a two-year period, from January 2016 to December 2017, we observed that the number of in-class training sessions offered for the sampled regions ranged from one to five sessions. (See Figure 1).

Figure 1 - OHS Workplace Committee and Representative Classroom Training Sessions Delivered between January 2016 and December 2017 for the regions covered in the Audit Sample

OHS Workplace Committee and Representative Classroom Training Sessions Delivered between January 2016 and December 2017 for the regions covered in the Audit Sample

Number of Sessions Delivered	Region
2	Atlantic
5	Greater Toronto Area
5	Headquarters
2	Northern Ontario Region
4	Prairie
1	Souhern Ontario Region

35. Without complete training, there is a risk that committee members and representatives are not fully equipped to discharge their duties and responsibilities and that processes are not consistently applied.

Recommendation 1 of this report addresses issues with training, and Recommendation 2 addresses issues with roles and responsibilities.

8.3 Compliance with Legislative Requirements

Hazardous Occurrences

36. The essential part of an effective OHS program is the hazardous occurrence reporting process that can be used to direct efforts into preventing accidents and time loss management. The CLC^{Footnote 11} stipulates that every employer shall investigate all hazardous occurrences. The employer must appoint a qualified person to investigate each workplace hazardous occurrence reported, usually a supervisor who has the knowledge of work procedures and safety requirements where the hazardous occurrence took place. The workplace committee or representative is expected to participate in the investigation and comment on the findings and corrective measures. A Hazardous Occurrence Investigation Report (HOIR) is to be shared with the workplace committee or representative, the regional OHS advisor and the national OHS advisors and submitted to Employment and Social Development Canada (ESDC) – Labour Program in certain circumstances.

37. The following three types of hazardous occurrences must also be reported to ESDC – Labour Program annually: disabling injuries, minor injuries and other hazardous occurrences.^{Footnote 12} During the audit scope period the Agency reported 1,815 hazardous occurrences, whereby disabling injuries accounted for 27%, minor injuries accounted for 34% and other types of hazardous occurrences accounted for 39%. (See Figure 2)

Figure 2 - Hazardous Occurrences and Investigations Reported, 2016 and 2017

Hazardous Occurrences and Investigations Reported, 2016 and 2017

Types of Incidents	Number of Occurrences and Injuries
	2016	2017
Disabling Injuries	237	202
Minor Injuries	283	233
Other Hazardous Occurrences	785	33

Note: Management indicated that the significant difference between 2016 and 2017 of other hazardous occurrences is due to a clarification of the definition of “other” and a change in the Control and Defence Tactics courses and recertification sessions at the training facilities, may also have helped reduce the number of other hazardous occurrences.

38. The audit team selected a sample of 141 HOIRs from the workplaces visited to assess whether they contained the appropriate information and followed the established process. All reports reviewed contained the necessary information, including corrective actions to address hazards, and followed the established approval process, with the exception of five reports which did not contain all required signatures. While the forms were almost all complete, it was noted that it was often the employee who completed the HOIR and had it signed by the supervisor, as opposed to being completed by the supervisor. This further supports that individuals and workplace committee members are not always clear on their roles and responsibilities.

Policy Health and Safety Committee

39. Every employer who employs directly three hundred or more employees shall establish a policy health and safety committee and select and appoint its members.^{Footnote 13} The PHSC, which consists of employee and employer representatives, is responsible for addressing health and safety matters through the development, implementation, and monitoring of policies and programs that promote the health and safety of employees. According to the CLC Part II^{Footnote 14}, a policy committee shall meet during regular working hours at least quarterly and, if other meetings are required as a result of an emergency or other special circumstances, the committee shall meet as required during regular working hours or outside those hours. For the period audited, the committee met the required number of times per year and demonstrated that OHS issues are discussed.

Workplace Health and Safety Committee Activities

40. A workplace committee is a joint forum for employer and employees to work together to improve workplace health and safety. Local management designates a management representatives to represent the employer, and the union of represented employees selects employee members. In workplaces with 19 employees or less, a health and safety representative must be selected.

41. According to the CLC Part II^{Footnote 15}, “a workplace committee shall meet during regular working hours at least nine times a year at regular intervals and, if other meetings are required as a result of an emergency or other special circumstances, the workplace committee shall meet as required during regular working hours or outside those hours.”. As for representatives, they are to meet with the employer as necessary to address health and safety matters.

42. All 23 workplaces in the audit sample met the requirement: 19 workplace committees were established and 4 representatives were appointed. The workplace committees met on a regular basis to di workplace concerns and hazards, as well as mitigating actions. Health and Safety representatives stated that all OHS related issues were reported to management to be addressed as needed.

43. Good practices were observed at some work sites where staff from various sectors and occupations participated on the workplace committees, including in some instances, the chief of operations. Committees in some work locations also appointed alternates to attend meetings as shift work can result in a difficulty to schedule meetings. This allowed for quorum to be met and for the meetings to proceed.

44. We reviewed workplace committee meeting minutes to assess the number of meetings that were held per year. To determine if each workplace was compliant, a minimum of nine meetings needs to be held per year. Not all workplace committees met the required number of times per year: in the sample of 19 workplace committees, 14 met the required number of times (74%) in 2016, and 15 in 2017 (79%).

45. Employers must ensure that all or part of the workplace is inspected every month by the workplace committee or the health and safety representative, so that the entire workplace is fully inspected in the course of the year^{Footnote 16}. This expectation is also stated in the Agency's OHS Framework.

46. The audit looked at whether workplace inspections were conducted and documented. To determine if each workplace was compliant, a minimum of twelve inspections needs to be held per year. Of the 23 workplaces visited, 10 (43%) of workplaces conducted the required number of inspections in 2016, and 8 (39%) in 2017. These numbers do not account for inspections that were reported as having occurred but for which no supporting evidence was provided. Reasons mentioned by workplace committee members and representatives as to why these inspection completion rates were low included difficulty in scheduling inspections due to variable shift schedule arrangements and operational requirements.

47. To provide a different lens on these results, Figure 3 presents the progress towards achieving compliance with the legislative requirements of nine meetings and twelve inspections per year based on evidence received from each workplace visited^{Footnote 17}. Progress towards meeting the required number of committee meetings has improved from 2016 to 2017 for all regions, however improvements are still required for meeting the required number of workplace inspections for the regions of the Greater Toronto Area, Prairie, and Southern Ontario.

Figure 3 - Progress towards Compliance for OHS Workplace Committee Meetings and Inspections for 2016 and 2017

Progress towards Compliance for OHS Workplace Committee Meetings and Inspections for 2016 and 2017

Region	2016 Workplace Committee Meetings	2017 Workplace Committee Meetings	2016 Workplace Inspections	2017 Workplace Inspections
Atlantic	100%	100%	98%	100%
Greater Toronto Area	89%	83%	63%	44%
Headquarters	89%	100%	83%	92%
Northern Ontario Region	67%	89%	42%	83%
Prairie	78%	100%	45%	60%
Southern Ontario Region	96%	94%	63%	60%

Note: The percentages for the number of committee meetings are based on 19 workplace committees, and the number of inspections, on 23 work sites. The number of sites per region varies – see Appendix B for the Audit Sample.

48. Ensuring committee meetings are occurring nine times a year and that required workplace inspections are taking place monthly is important so that health and safety concerns are identified, discussed and resolved in a timely manner. Communicating documentation requirements of inspections and identification of hazardous occurrences can improve the accuracy of information externally reported by the Agency. A lack of proper documentation and tracking could result in missed opportunities to identify trends and implement corrective/preventive measures to reduce re-occurrences.

8.4 Monitoring and Reporting

Monitoring

49. Effective monitoring processes, assessment of results and corrective measures help ensure that minimum legislative requirements are met and that health and safety issues are addressed. Monitoring of health and safety is a shared responsibility between various OHS stakeholders. Regional advisors are responsible for monitoring the compliance with requirements for their region by reviewing the workplace committee reports and activities, and national advisors are responsible for compiling the information on injuries for submission to the Labour Program.

50. The audit looked at the processes in place to collect, compile and analyze information to monitor the OHS program. At the workplace level, a workplace committee report is completed by committee co-chairs, which includes the number of workplace committee meetings and inspections. In the regions, OHS advisors log disabling injuries requiring the completion and submission of workplace compensation forms and this log is forwarded to national advisors. They also track required training for workplace committee members and representatives. National advisors compile information to present to the PHSC for monitoring purposes. These include quarterly compliance reports related to required workplace committee meetings and inspections, Hazardous Occurrence Investigation Reports and security incident reports.

51. Although some quantitative information was captured, limited monitoring activities were performed by the regional or national advisors to ensure that legislative requirements were met and that hazards in the workplace were reduced or eliminated. The audit found that regional advisors obtained the information from stakeholders in their region but did not consistently verify and review the data received, such as the minutes from committee meetings and workplace inspections. As well, although regional advisors keep a training log and rely on training and learning centres to keep records of all training completed, it is not monitored further.

Reporting

52. Under the COHSR^{Footnote 18}, federally regulated employers must submit two annual reports to the ESDC Labour Program:

• 1) The Employer’s Annual Hazardous Occurrence Report, which records the Agency’s number of disabling and minor injuries, deaths, occupational diseases and other hazardous occurrences; and
• 2) The workplace committee report, which summarizes the annual activities of individual workplace committees.

53. The Agency prepares the Employer’s Annual Hazardous Occurrence Report and submits it to ESDC in March of every year. As for the workplace committee report, most workplace committees completed and submitted these reports to ESDC.

54. To report internally to management, various types of reports were prepared such as the workplace committee reports and reports on compliance rates with regard to legislative requirements. In an effort to improve oversight and monitoring, the OHS section developed quarterly report cards for each region to provide RDGs with OHS compliance results. The report cards include regional information on the number of workplace committee meetings, workplace inspections and mandatory OHS training completion rates for employees and identifies workplaces that are trending towards non-compliance. They do not include training completion rates for workplace committee members and representatives.

55. The audit reviewed a sample of OHS reports and noted three issues. Firstly, we noted discrepancies in the performance data when comparing statistics on workplace injuries: information reported at individual workplaces did not always match with information reported by regional or national advisors. Similarly, when reviewing information on workplace compliance with legislative requirements, inconsistencies were found in the number of workplace committee meetings and inspections reported internally and externally to ESDC. Additionally, the performance information reported by workplace committees did not always correspond to the numbers presented in the quarterly report cards for RDGs.

56. Secondly, no qualitative analysis was conducted by the workplace committees or regional advisors to identify trends in workplace hazards. The Agency is missing an opportunity to potentially prevent hazardous reoccurrences by not conducting trend analysis on types of injuries or other OHS related incidents.

57. Lastly, it was noted that there was no common electronic system to compile information from the regions. Instead, templates are sent to the regions and regional advisors manually enter the information and submit them to the OHS section once completed. This creates a risk of error and could explain the discrepancies found in the reports. A common electronic system to record the information could improve the quality and accuracy of the information reported by the various stakeholders, and allow for the program to perform qualitative analysis to identify trends in workplace hazards.

58. The audit also assessed whether performance information was reported to senior management. The PHSC, which is co-chaired by the Vice-President of HRB and a union representative, is the advisory committee responsible for OHS matters. The PHSC does not formally report to the Executive Committee (EC) on matters regarding health and safety of employees. The last information presented to EC was in March 2018 and was related to the incident regarding an officer in 2017 and the planned preventive measures. Other than that presentation, performance information regarding OHS workplace committee meetings and inspections and injuries was last reported to the EC in February 2015. Similarly, there is limited oversight on the HPP, as performance and progress are not reported to the EC. Therefore, an opportunity exists to monitor and oversee the OHS program, including HPP activities, at the executive level to ensure its effectiveness.

59. Overall, comprehensive monitoring of OHS activities should be conducted and performance information should be validated for data accuracy and be presented to senior management on a regular basis.

8.5 Hazard Prevention Program

60. Given the Agency’s operating environment, the increasing complexity of work and the wide range of hazards, measures need to be in place to prevent or minimize workplace hazards and incidents from occurring. Every employer must develop, implement and monitor a program for the prevention of hazards that includes the following six components: 1) an implementation plan, 2) a hazard identification and assessment methodology, 3) a hazard identification and assessment, 4) preventive measures, 5) employee education; and 6) a program evaluation.^{Footnote 19}

61. At the Agency, the Director General, LRCD, has the authority and overall responsibility to manage all aspects of the Hazard Prevention Program (HPP). The PHSC and the workplace committee members and representatives are responsible for participating in the development and monitoring of the prevention of hazards in the workplace as per the OHS Framework.

62. The audit examined the hazard prevention program to determine whether a framework with priorities, timelines, responsibilities and resources was established to ensure the prevention of hazards.

63. The Agency developed an HPP in 2007. It should have also included an Implementation Plan, summarizing HPP roles and responsibilities and specifying associated timeframes for each component. With the approval of the Agency’s Implementation Plan in January 2018, the HPP now comprises all six components. At the time of the audit, certain components were outdated in accordance with prescribed revision timelines or based on changes in work conditions. Only the implementation plan and the hazard identification and assessment methodology were up-to-date, while the hazard identification and assessments were in the process of being conducted. The other three components - preventive measures, employee education; and a program evaluation - will require an update or a revision, based on the results of the completed hazard identification and assessments currently in progress.

64. An important component of the HPP consists in the hazard identification and assessment, which the Agency calls the “job hazard analysis” (JHA). A JHA is a procedure which helps integrate accepted safety and health principles and practices into a particular task or job operation. Each task of the job or occupation is analyzed to identify potential hazards, assess risk and determine appropriate preventive measures. When a change in health and safety or workplace conditions indicates that a new or increased hazard may be present, it is necessary to update the JHA.

65. When the Agency initially developed the HPP in 2007, only three JHAs existed to match three work occupations. Since then, there were changes around operations and new occupations and tasks have emerged. However, an update or revision in JHAs did not follow. Therefore, the JHAs do not reflect current work conditions. An evaluation conducted in 2013 by a national OHS advisor and a member of the PHSC, recommending that all job occupations be identified and that a JHA be completed for those that posed a significant risk to the health and safety of employees, further supports the requirement to complete JHAs. More notably, a 2017 Direction^{Footnote 20} from the ESDC’s Labour Program required the Agency to assess hazards in the workplace by updating a JHA that was outstanding since 2014.

66. At the time of the audit, the Implementation Plan identified eight occupations to replace the three originals, and added seven occupations to reflect other job occupations within the Agency. Thirteen JHAs were planned to be conducted by June 2020, of which seven were due by December 2018. Five of the seven JHAs due for December 2018 did not meet the targeted completion date.

67. We noted that no prioritization exercise was documented to determine which JHAs were to be conducted first nor did we see evidence that priority was given to the development of JHAs based on recent events, incidents, or operational risks. The first two JHAs that were started as part of the Implementation Plan were to achieve compliance. One is to respond to a complaint and the other is to address the 2017 direction issued by ESDC. Ensuring that the JHAs are prioritized based on an assessment of risks would help the OHS section focus its effort and resources on the areas of greatest exposure to hazards and threats.

68. In accordance with the Canada Occupational Health and Safety Regulations (COHSR), Part XIX^{Footnote 21}, progress on the implementation of preventive measures should be monitored and the timeframe of the implementation plan should be reviewed regularly and revised as necessary. A good hazard prevention program can prevent workplace accidents and injuries while streamlining the employer’s health and safety activities.

69. The audit examined whether progress of scheduled activities on the Implementation Plan was monitored. The Implementation Plan is a standing item on the PHSC agenda. It was difficult to assess what was discussed due to limited documentation of records of decisions. Other than the PHSC, it was difficult to assess formal program monitoring of the Implementation Plan due to a lack of documentation.

70. Further, while the Implementation Plan was developed in 2018, it lacked clarity on timeframes for revisions of the six HPP components, start dates for JHAs, assigned responsibilities and resources devoted to conducting the activities and it did not provide information on how monitoring of the implementation plan would occur. An opportunity exists to add precision to the Implementation Plan to ensure its success and help the PHSC perform its monitoring function.

71. A lack of monitoring and oversight of the HPP could lead to delays in the implementation of scheduled activities. Also, it could impede the Agency from implementing appropriate and timely measures to prevent the occurrence of injuries and other hazardous situations, as well as put the Agency at risk regarding compliance with the CLC and the direction issued by ESDC. In order to ensure the prevention of hazards, improvements in the monitoring of the HPP are needed.

Appendix A – About the Audit

Audit objective and scope

The objective of the audit was to provide assurance that the Agency has effective management controls and practices in place to support its OHS program and to ensure compliance with legal requirements of the Canada Labour Code Part II and related regulations.

The audit scope included an assessment of the:

• governance, management and oversight of the OHS Program;
• risk management practices in place at select POEs and Agency workplaces; and
• key business practices of stakeholders with OHS responsibilities in managing workplace hazards and risks.

The file review focused on the period of January 1, 2016 to May 1, 2018.

The audit scope excluded the following:

• The CBSA Wellness Programs including, the Worker’s compensation program, disability management and return to work after an injury or another hazardous occurrence, as well as violence prevention, psychological well-being and mental health aspects of the workplace. It is anticipated that these will be addressed in the Office of the Auditor General Audit of Healthy Workplace currently being conducted.
• Physical security, building emergency operations or fire prevention programs, with the exception of how these activities are considered in health and safety inspections, workplace committee and representative assessments.
• A technical review of compliance with the Canada Labour Code and its Regulations, i.e. inspection of tools and equipment; and handling and storage of hazardous substances.
• The Agency’s international office locations: while employees are protected by the CLC, these workplaces are regulated by a different jurisdiction. The international locations occupied by CBSA employees are a shared responsibility between the CBSA and Global Affairs Canada.
• Provincial and territorial OHS activities, operations and counterparts.
• Other persons in the workplace to whom Part II of the CLC does not apply (i.e., visitors, travellers).

Risk assessment

A preliminary risk assessment was conducted to identify potential areas of risk and audit priorities. This assessment was based on interviews with various stakeholders involved in the OHS Program at Headquarters, site visits at various locations in the Quebec Region, and a review of documentation related to OHS. The following key risk areas were identified.

Governance and Accountability

• 1. Roles, responsibilities and accountabilities related to the OHS program may not be adequately defined, documented, and communicated.
• 2. Oversight committees may not be well-designed to effectively oversee the OHS program, including the HPP.
• 3. There is a risk that the decentralized model for the OHS Program, with functional direction from the OHS section in HQ and Regional implementation via the Operations Branch, may impact the Labour Relations and the OHS Advisors influence over health and safety issues in the regions.

Business Processes

• 4. There is a risk that required OHS business processes or safety protocols may not be performed to a consistent and acceptable level of quality across the Agency’s regions.
• 5. There is a risk that key business processes such as the planned Job Hazard Analyses may not be completed in a timely fashion.
• 6. There is a risk that there may be a misalignment of the OHS activities currently underway and the priority of implementing the Hazard Prevention Program Implementation Plan.

Monitoring, Information for Decision Making and Reporting

• 7. There is a risk that information to support risk identification and priority setting for the treatment, mitigation and monitoring of workplace risks is not being compiled, analysed and reported.
• 8. There is a risk that the Agency is unable to collect and record OHS information (compliance data regarding inspections, workplace committee meetings, training, injury rates) in a timely and accurate manner.
• 9. There is a risk that employees may be exposed to chemical, nuclear, or other hazards resulting from deliberate actions if key business processes are not completed and/or updated in a timely fashion or in response to emerging risks.

The audit was conducted in accordance with the Treasury Board Secretariat Policy and Directive on Internal Audit and the Institute of Internal Auditors’ International Standards for the Professional Practice of Internal Auditing in the Government of Canada.

In order to conclude on the audit objective, the following methods have been used to gather evidence:

• Reviewed applicable legislation, policies, directives and procedures governing the management of OHS.
• Interviewed the OHS functional management in Headquarters and the OHS/Labour Relations regional advisors, and with management from Operations Branch in the regions.
• Interviewed members of the PHSC, employer and employee representatives of workplace committees.
• Reviewed and conducted analysis of PHSC, select workplace committees meetings minutes.
• Reviewed and conducted analysis of a sample of workplace inspection reports, injuries and hazardous Occurrence Reports.
• Conducted site visits and walkthroughs of selected work environments to observe and discuss processes, procedures and controls concerning various workplace safety hazards. Site visits for examination will include POEs (large and small) and offices in the Greater Toronto Area, Southern Ontario Region, Northern Ontario Region, Atlantic and Prairie regions as well as the Training Centre in Rigaud, the Inland Enforcement Operations office in Ottawa and the CBSA Forensic Laboratory in Ottawa.

Audit criteria

The audit criteria are aligned with the Government’s Management Accountability Framework (MAF), the framework of Core Management Controls and Audit Criteria (CMC) established by the Office of the Comptroller General and the Committee of Sponsoring Organizations of the Treadway Commission (COSO) Principles of Effective Internal Control.

Given the preliminary findings from the planning phase, the following audit lines of inquiry and criteria were selected:

Appendix B – Audit Sample

The following factors were considered when selecting the sample of ports of entry:

• Resource limitations and practicality (i.e. remote ports of entry were excluded for this reason);
• Coverage of ports with both high and low volumes of injuries and hazardous occurrences;
• Coverage of regions;
• Coverage of modes; and
• Coverage of occupations.

Appendix C – CBSA Specific Roles and Responsibilities for Occupational Health and Safety Matters

Appendix D –List of Acronyms

CBSA

Canada Border Services Agency

CLC

Canada Labour Code

COHSR

Canada Occupational Health and Safety Regulations

DG

Director General

ESDC

Employment and Social Development Canada

HOIR

Hazardous Occurrence Investigation Report

HPP

Hazard Prevention Program

HRB

Human Resources Branch

JHA

Job Hazard Analysis

LRCD

Labour Relations and Compensation Directorate

OHS

Occupational Health and Safety

PHSC

Policy Health and Safety Committee

POE

Port of entry

RDG

Regional Director General

TDD

Training and Development Directorate

Date modified:

2019-08-13