Transportation Safety Board of Canada - Internal Audit - OSH Training  and Personal Protective Equipment
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Transportation Safety Board of Canada - Internal Audit - OSH Training and Personal Protective Equipment

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TRANSPORTATION SAFETY BOARD OF CANADA Internal Audit of OSH Training and Personal Protective Equipment FINAL REPORT Submitted to Transportation Safety Board of Canada th200 Promenade du Portage, 4 Floor Gatineau, Canada K1A 1K8 Submitted by: Samson & Associates samson@samson.ca July 20, 2009 TABLE OF CONTENT EXECUTIVE SUMMARY................................................................................................ 1 1.0  BACKGROUND ..................................................................................................... 3  2.0  AUDIT OBJECTIVES, CRITERIA AND SCOPE ............................................. 4 3.0  METHODOLOGY ................................................................................................. 5 4.0  AUDIT OBSERVATIONS ..................................................................................... 6 4.1  COMPLIANCE TO CANADA LABOUR CODE AND TO TREASURY BOARD POLICIES ................ 6 4.2  COMPLIANCE WITH THE TSB OSH TRAINING POLICY AND STANDARDS .............................. 8 4.3  IMPLEMENTATION OF TSB PERSONAL PROTECTIVE EQUIPMENT STANDARDS ................. 12 APPENDICES: APPENDIX A: BEST PRACTICES APPENDIX B: CRITERIA FOR EACH AUDIT OBJECTIVE APPENDIX C: AUDIT STEPS APPENDIX D: MINIMUM PPE REQUIREMENTS Transportation Safety Board ...

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         TRANSPORTATION SAFETY BOARD OF CANADA   Internal Audit of OSH Training and Personal Protective Equipment  FINALREPORT   Submitted to   Transportation Safety Board of Canada 200 Promenade du Portage, 4thFloor Gatineau, Canada K1A 1K8    Submitted by:  Samson & Associates samson@samson.ca   July 20, 2009
      
 
TABLE OF CONTENT   
  EXECUTIVE SUMMARY................................................................................................ 1  1.0 ................................ AB.... ...OUNDCKGR.................... 3..........................................  2.0 AUDIT OBJECTIVES, CRITERIA AND SCOPE.............................................4  3.0 ................ METHODOLOGY ..................................................................5 .... ...........  4.0 AUDIT OBSERVATIONS.....................................................................................6  4.1 COMPLIANCE TOCANADALABOURCODE AND TOTREASURYBOARDPOLICIES ................ 6 4.2 COMPLIANCE WITH THETSB OSHTRAINING POLICY AND STANDARDS.............................. 8 4.3 IMPLEMENTATION OFTSB PERSONALPROTECTIVEEQUIPMENTSTANDARDS................. 12    APPENDICES:  APPENDIX A: APPENDIX B: APPENDIX C: APPENDIX D:
 
BEST PRACTICES CRITERIA FOR EACH AUDIT OBJECTIVE AUDIT STEPS MINIMUM PPE REQUIREMENTS
 
 
 
Transportation Safety Board Final Report Audit of Occupational Safety and Health Training and Personal Protective Equipment  
EXECUTIVE SUMMARY
The Transportation Safety Board (TSB) authorized a compliance audit of their Occupational Safety and Health (OSH) Training Policy and their Occupational Safety and Health (OSH) Personal Protective Equipment (PPE) Standards with three specific objectives:  1) Assess the extent of compliance of TSB OSH training policy and standards and personal protection equipment standards to the Canada Labour Code and Treasury Board policy requirements  2) Assess the extent of staff compliance with TSB’s OSH training policy 3) Assess the extent of staff compliance with TSB’s personal protection equipment policy and standards.  Auditors have assessed each of these objectives with regard to the Canada Labour Code, the Occupational Health and Safety Regulations under the Canada Labour Code, and Treasury Board Occupational Health and Safety policies and guidelines.
This audit was conducted between February 13 and April 30, 2009 in accordance with the Treasury Board Policy on Internal Audit and the Institute of Internal Auditors for the Professional Practice of Internal Auditing were applied. It is our assessment that the TSB OSH training policy and PPE policy and standards are compliant with relevant legislation. The audit found a high level of staff compliance to the OSH training and the PPE policies. However, it is in the area of documentation that TSB has the greatest risk and the greatest opportunities for improvement. 
The audit found that TSB already employs best practices in many areas of their OSH training and their PPE program and is committed to continuous improvement; a mark of a good OSH program. “Appendix A” is a summarized list of bestpractices in OSH training programs and OSH PPE programs. However, there are areas where policy, process, and controls could be improved to ensure that the TSB’s reputation as a proponent of safety, and as an organization responsible for the safety of their employees, is not at risk. Although the audit finds that TSB has appropriate policies in place, due diligence requires that the policies must be adequately implemented with sufficient and complete documentation. This due diligence is important as a legal defence for persons or organizations charged under occupational health and safety legislation. If charged, a defendant may be found not guilty if he or she can prove that due diligence was exercised. In other words, the defendant must be able to prove that all precautions, reasonable under the circumstances, were taken to protect the health and safety of workers.
The specific audit recommendations related to each objective are as follows:  The TSB OSH training policy and standards and personal protection equipment standards comply with the Canada Labour Code and Treasury Board policy requirements.  1. The National OSH Policy Committee should review the personal protection equipment policy and standards and attached guidelines and provide clarity in regards to maintenance, record keeping, and obligation for persons granted access to the sites.  
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Transportation Safety Board Final Report Audit of Occupational Safety and Health Training and Personal Protective Equipment  
 Staff compliance with TSB OSH training standards.  2. The Manager of Human Resources in conjunction with Responsibility Centre managers should develop an orientation program for all new employees that includes a review of policies, overall responsibility for the implementation of the policies and information on the corporate reference centre and how to access policies on the intranet. As a best practice, the TSB should distribute their OSH policies annually to all employees as a part of National Occupational Health and safety week.  3. A comprehensive tool or system should be implemented to monitor types of OSH training required, mandatory completion or renewal dates, and actual training completed for each employee. The system should contain a notification or reminder function for mandatory dates and managers should be accountable for ensuring that notifications are acted upon and that training is received in a timely fashion.  4. Responsibility Centre Managers should be responsible for entering information and maintaining accurate records within the provided system. Further, they should institute a point of control to ensure that courses approved are completed by the employee, that the information is entered into HRIS, and that certifications or proof of attendance is included in individual training files.   5. The Directors of Investigations should mandate a documented site safety assessment. The site safety assessment should identify hazards that would allow Investigators to assess the minimum OSH training required for persons on site.  Staff compliance with TSB personal protection equipment standards   6. The Manager of Finance and Administration should review practices for maintaining a PPE inventory to ensure that requests for PPE can be filled in a timely fashion. Additionally, expired equipment and equipment that no longer meets the specifications identified in the TSB PPE standards should be removed from inventory.  7. Responsibility Centre Managers should enforce the policy guidelines by ensuring administrative officers maintain complete and accurate information on PPE issued to employees.  8. of Investigations should mandate a documented site safety assessment. The site safetyThe Directors assessment should identify hazards that would allow Investigators to assess minimum PPE requirements for persons on site.  9. use of appropriate PPE as per the policy.The Directors of Investigations should enforce the  10. The National OSH Policy Committee should update the existing OSH PPE standards to include minimum PPE requirements for accident investigation sites.  11. employees review the PPE that theyManagers should institute an annual process requesting that have been issued and provide a declaration that the equipment is in good working order.  
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Transportation Safety Board Final Report Audit of Occupational Safety and Health Training and Personal Protective Equipment  12. To ensure that PPE in use meets the specifications required, Corporate Services in consultation with Responsibility Center managers should review the practice of allowing employees to purchase standard PPE locally in non-urgent situations.    1.0 Background  The Transportation Safety Board of Canada (TSB) is an independent agency created in 1990 by an Act of Parliament (Canadian Transportation Accident Investigation and Safety Board Act). It operates at arm’s length from other government departments and agencies such as Transport Canada, Fisheries and Oceans Canada and the National Energy Board to ensure that there are no real or perceived conflicts of interest. The TSB’s only objective is the advancement of transportation safety. This mandate is fulfilled by conducting independent investigations into transportation occurrences. The purpose is to identify the causes and contributing factors of the occurrences and the safety deficiencies evidenced by an occurrence. The TSB then makes recommendations to improve safety and reduce or eliminate risks to people, property and the environment.  The TSB has approximately 230 employees located in its Head Office in Gatineau, an engineering laboratory located in Ottawa, and eight regional offices located in major cities across Canada. Approximately 65% of employees may be required to deploy to occurrence sites in the course of their duties. Occurrence sites typically present a wide range of risks and hazards to the health and safety of employees.  At the time of the audit, the Transportation Safety Board was organized with an Executive Director and two directorates: Investigation Operations and Corporate Services. Within Investigation Operations, there were three modal branches (marine, rail and pipeline, and air) and four supporting units (Engineering Branch, Macro Analysis, Human Performance, and Publishing and Linguistic Services). Within Corporate Services there were five units supporting the operations of the TSB.  The TSB has established a National OSH Policy Committee with representatives from each union and management. The mandate of this committee is outlined inAPPENDIX“A” of their Occupational Health & Safety Policy. Additionally, there is a workplace Safety and Health Committee for the Head Office as well as the Engineering Branch in Ottawa. There are also Health & Safety representatives in each regional office.  Part of the mandate of the National OSH Policy Committee is to participate in the development of health and safety policies and programs, and to participate in the development and monitoring of a program for the provision of personal protective equipment, clothing, devices or materials. The TSB National OSH Policy Committee has therefore conducted a risk assessment and developed OSH training standards and personal protective equipment standards. These policies were developed with input from each of the modes, the support units, and other administrative employees impacted by the policies. These standards were approved and issued for implementation in May 2007 and August 2006 respectively.  
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Transportation Safety Board Final Report Audit of Occupational Safety and Health Training and Personal Protective Equipment  Upon adopting the OSH training policy, the policy was sent to each manager and was also sent directly to each employee during National Occupational Safety & Health week that same year. It is a matter of course that policies are available to all employees on the intranet system.  Every employee within TSB is affected by the TSB OSH training policy and most of the TSB employees are affected by the TSB personal protection equipment standard. 2.0 AUDITOBJECTIVES, CRITERIA ANDSCOPE  2.1 Audit Objectives  The Transportation Safety Board (TSB) authorized a compliance audit with three distinct objectives:  1. To assess the extent that the TSB OSH training policy and standards and personal protection equipment standards comply with the Canada Labour Code and Treasury Board policy requirements 2. extent of staff compliance with TSB OSH training standardsTo assess the 3. To assess the extent of staff compliance with TSB personal protection equipment standards.  2.2 Audit Criteria  The audit adopted the criteria based on the Canada Labour Code, Treasury Board Policies, TSB OSH Training Standards, and TSB PPE Standards. These are further detailed inAPPENDIX“B” for each of the audit objectives.  2.3 Scope  The audit included all aspects of the TSB OSH Training and personal protective equipment standards and all TSB personnel covered by the standards in Head Office and the regions. The audit reviewed the adequacy of internal controls and practices for ensuring that:  compliant with the Canada Labour Code and the relevant Treasury BoardTSB practices are  policies;  Managers properly implement the approved standards;  Employees are properly trained and equipped for the work they are asked to perform; and  Employees make appropriate use of the equipment they are provided.  Scope Exclusions  The audit did not include:   sections of TSB OSH policies other than the training and personalAn examination of other protective equipment standards;  A review of employee occupational fitness and immunizations;  A review of overall workplace safety programs;
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Transportation Safety Board Final Report Audit of Occupational Safety and Health Training and Personal Protective Equipment  
 detailed contents of OSH training courses; andA review of the  A review of costs associated with OSH training and personal protective equipment.  training and PPE policies as they relate toA review of staff compliance to the OSH subcontractors   3.0 METHODOLOGY  The audit was completed in four phases; a preliminary review phase, a fieldwork phase, a detailed examination phase, and a reporting phase which is this document.   3.1 Preliminary Review Phase  The preliminary review phase included a review of key documents to identify and familiarize the audit team with the policies under review and the relevant legislation and directives that guide the conduct of OSH training and personal protection equipment standards. This phase also included interviews with managers and key personnel from each mode; notably Air, Rail & Pipeline, Marine, the Operational Services Branch, Regional managers, and Corporate Services. We also included members of the National OSH policy committee and members of the Head Office and lab Workplace Safety and Health Committees in our interviews. The auditors went to regional offices in Edmonton, Toronto and Montreal as well as the Lab facility in Ottawa. At each location they were given a tour of the facility including the “shop” areas. Additionally, the auditors requested, and were granted access to the PPE of investigators at each location and conducted a visual inspection of the equipment displayed.   In this phase, the auditors developed questionnaires for Responsibility Centre Managers and Administrative Assistants to gather data on each of the identified criteria. The questionnaires in conjunction with the preliminary interviews was the main source of information to determine if employees are familiar with the TSB OSH training policy and to determine if employees are aware of their responsibilities related to OSH training and PPE.  The preliminary phase resulted in the development of a Policy Framework document which was used to audit the compliance of TSB’s Training Policy and Personal Protective Equipment Standards.  3.2 Fieldwork Phase  Using the information from the Policy Framework, the interviews and the questionnaires, the auditors were able to develop a risk assessment which was used to provide direction for the audit program. As part of the fieldwork phase, we developed a process flowchart of the OSH training process at TSB which was used to identify control points, documents required and responsibility for various parts of the process and also provides direction for the audit program. The audit team included an expert in Occupational Health and Safety who assisted with the identification of best practices in the area of OSH training and personal protection equipment and the resulting recommendations.  APPENDIX“C” of this report provides detailedsteps undertaken during the fieldwork.
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Transportation Safety Board Final Report Audit of Occupational Safety and Health Training and Personal Protective Equipment  
 3.3 Detailed Examination Phase  It is through detailed examination of information gathered in the fieldwork phase that we are able to develop our audit findings. To document our analysis we utilize Fact Sheets which include: the criterion as outlined, the current condition, the cause of the current condition, the effect of the current condition, and finally the recommendations. These fact sheets are the result of the detailed examination phase and were used to build the final report.  3.4 Reporting Phase  This report summarizes the audit observations and provides a conclusion in relation to the three audit objectives and audit criteria established at the outset of this audit engagement. Finally, the audit report identifies best practices and proposes recommendations to improve compliance to the policies in areas where non-compliance was found.  4.0 AUDITOBSERVATIONS  The following section provides a conclusion with respect to each of the three objectives established at the outset of this audit engagement as well as audit observations and recommendations when appropriate. 4.1 CMOLPAIE NC TOCADANA LARUOB CNA EO T DDOTSARUER YBRA DOPCIESOLI   OSH Training Policy  The criteria used to assess compliance of the TSB OSH training policy with applicable legislation are:  TSB OSH training policy and standards fully meet the requirements of the Canada Labour Code.  TSB OSH training policy and standards fully meet the requirements of Treasury Board policies.  The audit found that the TSB OSH training policy takes into consideration all of Part II of the Canada Labour Code, the accompanying Occupational Health and Safety Regulations, and the Treasury Board Occupational Health & Safety Policies and guidelines.  OSH Personal protection equipment standards  The criteria used to assess compliance of the TSB OSH Personal protection equipment standards with applicable legislation are:  
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Transportation Safety Board Final Report Audit of Occupational Safety and Health Training and Personal Protective Equipment   TSB personal protection equipment standards fully meet the requirements of the Canada Labour Code  TSB personal protection equipment standards fully meet the requirements of Treasury Board Policies  The audit found that the TSB PPE policy and standards are generally compliant with the Canada Labour Code Occupational Health and Safety Regulations and TSB Policies. However, clarity could be provided in the areas of PPE maintenance, record keeping, and obligation for persons granted access to the site as detailed below. Also, the existing PPE policy could be amended to reflect TSB PPE policy by including a requirement to provide PPE suitable for the gender of the user.  From the Canada Labour Code Occupational Health and Safety Regulations:  13.3 All protection equipment provided by the employer shall:   (a) be maintained, inspected and tested by a qualified person; and (b) where necessary to prevent a health hazard, be maintained in a clean and sanitary condition by a qualified person.  12.14 (1) A record of all protection equipment provided by the employer shall be kept by him in the work place in which the equipment is located for a period of two years after it ceases to be used.  (2) The record referred to in subsection (1) shall contain: (a description of the equipment and the date of its acquisition by the employer;) a (b) the date and result of each inspection and test of the equipment; (cnature of any maintenance work performed on the equipment since its) the date and acquisition by the employer; and (d) the name of the person who performed the inspection, test or maintenance of the equipment.  12.15 (1) Every person granted access to the work place who uses protection equipment shall be instructed by the employer in the use of the equipment. (3) The instructions referred to in subsections (2) shall be: (a) set out in writing; and (b) kept by the employer readily available for examination by every person granted access to the work place. From the Treasury Board Occupational Health and Safety directives:
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