Disclosure of internal audits 2009-2010

TRANSPORTATION SAFETY BOARD OF CANADA

Internal Audit of OSH Training and Personal Protective Equipment

FINAL REPORT

Submitted to

Transportation Safety Board of Canada
200 Promenade du Portage 4th Floor
Gatineau, Canada
K1A 1K8

Submitted by:

Samson & Associates
samson@samson.ca

July 20, 2009


TABLE OF CONTENT

APPENDICES:


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 best practices 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.

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. The Directors of Investigations should mandate a documented site safety assessment. The site safety assessment should identify hazards that would allow Investigators to assess minimum PPE requirements for persons on site.

9. The Directors of Investigations should enforce the use of appropriate PPE as per the policy.

10. The National OSH Policy Committee should update the existing OSH PPE standards to include minimum PPE requirements for accident investigation sites.

11. Managers should institute an annual process requesting that employees review the PPE that they have been issued and provide a declaration that the equipment is in good working order.

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 in APPENDIX "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.

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 AUDIT OBJECTIVES, CRITERIA AND SCOPE

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. To assess the extent of staff compliance with TSB OSH training standards
  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 in APPENDIX "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:

  • TSB practices are compliant with the Canada Labour Code and the relevant Treasury Board 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:

  • An examination of other sections of TSB OSH policies other than the training and personal protective equipment standards;
  • A review of employee occupational fitness and immunizations;
  • A review of overall workplace safety programs;
  • A review of the detailed contents of OSH training courses; and
  • A review of costs associated with OSH training and personal protective equipment.
  • A review of staff compliance to the OSH training and PPE policies as they relate to 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 detailed steps undertaken during the fieldwork.

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 AUDIT OBSERVATIONS

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 COMPLIANCE TO CANADA LABOUR CODE AND TO TREASURY BOARD POLICIES

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:

  • 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:

  1. be maintained, inspected and tested by a qualified person; and
  2. 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:

  1. a description of the equipment and the date of its acquisition by the employer;
  2. the date and result of each inspection and test of the equipment;
  3. the date and nature of any maintenance work performed on the equipment since its acquisition by the employer; and
  4. 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:

  1. set out in writing; and
  2. 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:

12.3.3 Protective clothing shall be:

  1. suitable for the gender of the user.
RECOMMENDATION:

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 as well as the requirement to provide PPE suitable for the gender of the user.

4.2 COMPLIANCE WITH THE TSB OSH TRAINING POLICY AND STANDARDS

In assessing staff compliance to the TSB OSH training policy, the auditors believe that internal procedures could be improved to enhance awareness of the policy amongst new employees, to ensure that hazards of field operations are documented, and to strengthen controls related to the coordination, monitoring and record keeping of all OSH training.

The OSH training policy and standard articulates the overall policy and then goes on to identify specific roles and responsibilities. It includes a matrix that identifies training required for various groups of employees, notably persons actively involved in marine investigations, persons actively involved in pipeline investigations, persons actively involved in rail investigations, persons actively involved in air investigations, communications personnel, and administrative support (including other managers). This matrix identifies the type of training required, the groups for which the training is mandatory, optional, or not applicable, and the time frame in which the training is to be completed or renewed.

There is no specific position or unit to oversee OSH training. Within the OSH training policy, the responsibility to ensure training is received by employees is that of Senior Managers and Responsibility Centre Managers. The OSH training that is mandatory for all staff is coordinated by Corporate Services who also monitors the employees throughout the organization that require the training. Training that is mandatory only for administrative staff is also coordinated and monitored by Corporate Services. Training that is mandatory for modal employees is coordinated and monitored by the mode or region.

To receive training, employees are to complete a training approval form which is signed by the supervisor and the RC manager. The signed approval form is sent to Human Resources for retention in the training files. Once the training has been completed by the employee, the administrative officer is responsible for entering the information into the Human Resources Information System (HRIS) database and for ensuring that certificates or other proof of training is provided to Human Resources for the employee files.

The criteria used to assess staff compliance to the TSB OSH training policy and standards are:

  • Managers and employees are familiar with the TSB OSH policy and training standards
  • Managers ensure that required and recurring training is included in training plans and that employees complete the training within the prescribed timeframe
  • Managers have access to accurate, complete, timely, detailed information on OSH training of their employees.
  • Employees do not undertake work or expose themselves to situations for which they have not been properly trained.
  • Roles and responsibilities are carried out as outlined in the OSH training policy

4.2.1 NEW EMPLOYEES ARE NOT FAMILIAR WITH THE TSB OSH POLICY AND TRAINING STANDARDS

The current TSB OSH training policy and standard was adopted in May 2007. Upon adoption of the policy, it was sent to all managers. Later that same year, it was sent to all employees as part of the OSH awareness week. Additionally, the policy is available on the intranet and can be accessed by all employees.

In spite of all of these measures, information gathered in interviews and from the questionnaire show that a small number of employees and managers are not familiar with the OSH training policy. The employees identified have all been employed with TSB for less than one year. However, the audit also revealed that improvements could be made in the way policies are linked or cross-referenced to the standards on the intranet. The result is that employees are unaware of their own training requirements and managers are unable to plan for employees to take required training. During the review the auditors noted there was no standard orientation training for new employees that would provide an opportunity to identify the OSH training policy and its application at various levels. If employees are not aware of the training requirements within the policy, there is an increase risk that OSH training will not be requested or managers will not approve the requests and therefore employees will miss required training. This increases the risk of workplace accidents. However, the auditors also noted that Human Resources has identified the need for such an orientation and is reviewing the content and implementation requirements for providing orientation to new employees.

RECOMMENDATION:

2. The Manager of Human Resources in conjunction with Responsibility Centre managers should develop an orientation program for all new employees. The program should include a review of TSB policies, overall responsibility for the implementation of the policies and information on the corporate reference centre and how to access policies on the intranet. And, 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.

4.2.2 INADEQUATE CENTRALIZED INFORMATION TO ENSURE THAT RECURRING TRAINING IS INCLUDED IN TRAINING PLANS AND THAT EMPLOYEES COMPLETE THE TRAINING WITHIN THE PRESCRIBED TIMEFRAME

This criteria has two distinct parts. 1) Ensure required and recurring training is included in training plans, and 2) that employees completed the training within the prescribed timeframe.

1) Each mode, the operational services branch, and the support units have unique OSH training requirements due to the differences in the work they do, and each area has a training program in place. The modes, regions and operational services branch managers coordinate the required OSH training for their employees while Corporate Services coordinates the training that is mandatory for all employees. Managers are required to submit annual training plans for budget purposes. These plans identify specific OSH training required for employees and may be single or multi-year in nature. Therefore, although individual training plans are not readily available, the annual budget process does allow managers to ensure that training is included in training plans.

2) The practice of monitoring and tracking training varies between the modes, the operational groups, the regions, and the administrative areas of TSB. The auditors were unable to locate a single source of information that was complete, accurate and up to date in regards to training and therefore could not verify that training was completed or was completed within the prescribed timeframe. The information between the employee files, the HRIS reports and the spreadsheets was not consistent and rarely noted mandatory certification or recertification dates. The inconsistent information would indicate that administrative officers are not vigilant in providing copies of certificates to HR for retention in the employee training files and are not consistently entering data into the HRIS database.

It is management's responsibility to provide appropriate training to employees. If a serious workplace accident were to occur at TSB, it would be investigated by workplace safety and health agencies and TSB would be in a position of having to prove that the appropriate training was completed by the employee. 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.

RECOMMENDATION:

3. A comprehensive tool or system should be implemented that can 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.

4.2.3 MANAGERS DO NOT HAVE ACCESS TO ACCURATE, COMPLETE, TIMELY, DETAILED INFORMATION ON OSH TRAINING OF THEIR EMPLOYEES.

The OSH training policy states that Corporate Services is to provide and maintain an employee training database in HRIS for tracking of OSH training and certification. This database is available, but it is incomplete and there are no reports provided to managers from HRIS. Additionally, HRIS is a database that tracks names and dates of training completed and does not allow managers to monitor upcoming or recertification training requirements. In an effort to track training for their employees, managers maintain their own databases and/or training files and reference the source they have developed when they need access to detailed information and reports. Auditors found however, that these databases may not include records of training previously completed, and generally do not include information on training that is coordinated by Corporate Services, so the reports that the manager is relying upon are not complete. The fact that managers receive no reports from HRIS regarding training that has been completed shows a lack of control because there is no opportunity to verify the accuracy of the data within HRIS.

An additional problem encountered by the auditors when trying to compare training received with training on the matrix was a lack of a naming convention or standardized method to describe the training. The Rail and Marine Modes have the same company providing much of their training and although the training agenda was available, the course names were not consistent with the type of training in the matrix. Modal employees familiar with the training content verified that specific training identified in the matrix such as "Critical Incident Stress Management" was included as part of the "Transportation Disaster Response Family Assistance" training and the "Next of Kin" training, but there was no way to make this connection from information contained on the reports.

RECOMMENDATION:

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.

4.2.4 ADEQUATE CONTROL IS IN PLACE TO ENSURE EMPLOYEES DO NOT UNDERTAKE WORK OR EXPOSE THEMSELVES TO SITUATIONS FOR WHICH THEY HAVE NOT BEEN PROPERLY TRAINED.

The policy requires that Investigators in Charge (IIC's) ensure they are adequately trained in OSH and fully informed of the responsibilities they have on behalf of the employer. Interviews with staff as well as questionnaire responses strongly indicate that employees are aware of their responsibilities in regards to safety and use a great deal of situational control to ensure that they do not expose themselves to hazardous situations for which they may not have been properly trained. In addition, a review of the accident reports over the last three years supports this information by revealing that the incidents, with one exception were a result of ergonomic situations.

RECOMMENDATION:

None

4.2.5 ROLES AND RESPONSIBILITIES ARE NOT CONSISTENTLY CARRIED OUT AS OUTLINED IN THE OSH TRAINING POLICY

The TSB OSH training policy states that the OSH training matrix shall be reviewed and updated at least once every year by the National OSH Policy Committee and communicated to all managers and employees. According to the minutes of the National OSH Policy Committee, no such review has taken place since the policy was adopted in May of 2007. The Canadian Labour Code is silent on the requirements to review OSH Policies and a review of best practices found in the Canadian Centre for Occupational Health and Safety (CCOHS) indicates only that the policy itself should contain a "commitment to regular reviews of the policy and to monitor its effectiveness". Issues or problems with the OSH training policy are to be brought to the National Committee by the Workplace Committees and therefore, if the CLC has not changed, and TB policies have not changed, an annual review may be unwarranted and a poor use of limited committee time.

The OSH training policy also stipulates that IIC's are to ensure that a site safety assessment is done by trained personnel to identify any potential hazards before individuals are granted access to the site. A review of documentation in the investigation files and information gained in the interviews indicate that although IIC's may be conducting an informal site safety assessment, it is undocumented. Additionally, IIC's are not ensuring that individuals are trained and certified as required by the policy before being granted access to a site. Although the auditors understand that an incident must be responded to in a timely fashion, the lack of a documented site safety assessment leaves the TSB without a benchmark to assess whether employees were appropriately trained and prepared for the hazards encountered. If an employee was to have an accident on site, there would be no documentation on file to support that the employee was aware of the hazard or that the IIC made a correct assessment of the safety of the site.

RECOMMENDATIONS:

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.

4.3 IMPLEMENTATION OF TSB PERSONAL PROTECTIVE EQUIPMENT STANDARDS

Providing equipment to investigative personnel is standard throughout the modes and regions. Equipment that is common to all investigative personnel or equipment that requires the TSB insignia is purchased by Corporate Services. Some of this equipment is kept in sufficient supply that there is a modest inventory on hand, while other items are size dependent and must be specifically ordered. When an employee requires equipment, a request form is completed and signed by the Responsibility Centre manager. The equipment is requested from Corporate Services (stores) if it is one of the items they are responsible for. If the item is size dependent and does not require the TSB insignia (boots), the employee is encouraged to purchase it and submit a request for reimbursement. Additionally, if the item is urgently required or if Head Office has been unable to supply it, the modal or regional managers approve the purchase locally.

Although there is supply of PPE maintained in inventory at Head Office and in the regions, there is no process in place to maintain records on the PPE inventory at Head Office or in the regions. Additionally, although there is a requirement within the policy to keep records of PPE issued to employees, there is no process in place for keeping records of PPE that is approved and provided to employees.

Auditors have established that TSB is committed to reviewing and improving their personal protective equipment (PPE) standards and is conscious of the specific requirements of each of the modes. Additionally, interviews with personnel indicate that requests for PPE are rarely refused. Nonetheless, some areas are in need of improvement including: recording of PPE issued to individual employees, maintaining accurate and complete inventory lists, ensuring that equipment purchased by individuals meets the specifications outlined in the policy, and establishing clear guidelines based on best practices regarding PPE usage.

The criteria used to assess staff compliance to the PPE standards are:

  • Managers and employees are familiar with the TSB personal protective equipment standards.
  • Managers ensure that required equipment is provided to all employees on a timely basis.
  • Managers have access to complete, accurate, timely, detailed information on personal protective equipment for their employees.
  • Employees are aware of their responsibilities and do not undertake work or expose themselves to situations for which they do not have the appropriate protective equipment.
  • Employees make proper use of the protective equipment provided to them.
  • Employees maintain their equipment in good condition and ask for replacement items where needed.
  • PPE currently in use meets the specifications stipulated in the TSB PPE standards

4.3.1 MANAGERS AND EMPLOYEES ARE FAMILIAR WITH THE TSB PERSONAL PROTECTIVE EQUIPMENT STANDARDS.

The TSB personal protection equipment standard was approved in April 2007. The interviews as well as the questionnaires indicate that all areas of investigation and regional personnel are familiar with the TSB PPE standards. Although there are some employees according to the questionnaire that are not familiar with the PPE standards, these employees have been with TSB less than one year and are in administrative positions where PPE is not a requirement of their job.

RECOMMENDATION:

None

4.3.2 REQUIRED PERSONAL PROTECTIVE EQUIPMENT IS NOT PROVIDED TO ALL EMPLOYEES IN AN EFFICIENT MANNER.

Managers are responsible to ensure that employees have appropriate PPE. They approve employee requests for PPE which are then forwarded to headquarters. The employee responsible for "stores" will provide the equipment from inventory, or order it from an appropriate supplier. However, other PPE items are purchased locally, such as safety footwear. The manager gives the employee approval to purchase the PPE, and then the employee either purchases the item and requests reimbursement, or the administrator purchases the items on the corporate credit card.

Occasionally, items requested from Head Office are not provided to employees on a timely basis. There has been significant turnover in the position that is responsible for PPE inventory at Head Office and complete inventory records are not available. If TSB does not have the items in inventory they must be purchased from the supplier. In some instances the procurement documents revealed that the delay in issuing the equipment was due to supplier backorders. If equipment was not sent from Head Office to employees in a timely fashion, auditors found that managers would approve the purchase of items locally to ensure that employees had the appropriate PPE to carry out their responsibilities related to an investigation. If PPE is not issued to due to insufficient supply in inventory, or the PPE cannot be located because of incomplete records, employees are in a position where they must locally purchase items prior to starting the investigation. This is an inefficient use of time and resources.

The auditors noted that the Manager of Finance and Administration had recently requested a complete list of outstanding PPE items for all employees, and items confirmed by managers as required but still outstanding from Head Office will be acted on.

RECOMMENDATION:

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.

4.3.3 MANAGERS DO NOT HAVE ACCESS TO COMPLETE, ACCURATE, TIMELY, DETAILED INFORMATION ON PERSONAL PROTECTIVE EQUIPMENT FOR THEIR EMPLOYEES.

The PPE Policy clearly states that administrative officers are responsible to maintain records of PPE issued to staff. However, the practice of tracking individual PPE varies within the modes and regions. The audit team reviewed records kept by Corporate Services, by the modes, and by the regions, and found that with the exception of the Montreal office, individual employee PPE records are incomplete. The sample chosen revealed that there were instances that not only were records incomplete, they did not exist. There is no process in place to ensure that PPE requested from stores is documented for each employee and no process in place to ensure that PPE purchased individually meets specifications or is included in employee files. The result is that if a serious accident were to occur where an employee was not wearing proper PPE, there is no way for TSB to validate that their employees had in fact been issued the appropriate PPE.

RECOMMENDATION:

7. Responsibility Centre Managers should enforce the policy guidelines by ensuring administrative officers maintain complete and accurate information on PPE issued to employees.

4.3.4 EMPLOYEES ARE AWARE OF THEIR RESPONSIBILITIES AND DO NOT UNDERTAKE WORK OR EXPOSE THEMSELVES TO SITUATIONS FOR WHICH THEY DO NOT HAVE THE APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT.

Interviews along with questionnaires revealed overwhelmingly that employees are aware of their responsibilities related to the use of PPE and, in the case of responding to occurrences, they use a great deal of situational control. The local police, RCMP, fire or ambulance are normally present when the investigators reach the site. In the case of rail and pipeline incidents, officials from the rail or pipeline companies are also usually present. According to interviews, the IIC has a good idea of the hazards prior to entering the site, and if they don't have the appropriate training or equipment, or if they are unsure of the hazards that may exist, they don't go into the site.

RECOMMENDATION:

None

4.3.5 EMPLOYEES DO NOT ALWAYS MAKE PROPER USE OF THE PERSONAL PROTECTIVE EQUIPMENT PROVIDED TO THEM.

In trying to define "proper" use of equipment, the audit team looked for documented information on hazards that existed on the site. The sample of investigation files chosen revealed that there is no documented site safety assessment on file. Investigators indicated during the interviews that they do assess the safety of the site prior to entering the site but that the assessment is informal.

It is particularly in the air branch that the auditors determined a higher risk for proper usage of equipment exists. Without a safety assessment that documents hazards that exist at the site, there is no benchmark to specifically state whether PPE was required or used appropriately. TSB's OSH Policy states "IIC/Team Leaders are responsible while conducting an investigation to: ensure that team members are provided with and wear the appropriate protective equipment while on occurrence sites". Additionally, the guidelines for Safety Footwear and Hard Hats states "To protect against those hazards which continue to exist after all such control measures have been implemented, appropriate protective footwear/headwear must be used." Under specific responsibilities for investigators it states they are to "ensure that workers wear appropriate protective footwear/headwear at all times in areas where foot/head injury hazards exist.". All of these guidelines are appropriate, but without a written document of what the hazards were, validating after the fact whether proper PPE was used is subjective to the assessment of the IIC. Interviews with the air branch investigators have indicated that hardhats are often not worn because the IIC has assessed there is no danger of something falling on their head in the middle of a runway. Similar statements were made about safety footwear where the IIC has assessed there is no danger and therefore did not require protective footwear. Visual evidence of air crash sites, including the Air France crash site, confirms that individuals are not wearing PPE in instances where the audit group, using the criteria of "reasonable persons" believes that hazards do exist and warrant the use of protective headwear and footwear.

In light of the fact that there are no documented site assessments, stated minimum protective equipment requirements would give TSB a level of assurance that their employees are in fact protected against hazards that may exist and would provide a benchmark to definitively assess afterwards whether employees are properly using the stated minimum PPE. There are many examples of best practice that can be sited to ensure a minimum standard for protective equipment. One needs only to look at the standard imposed by the rail companies in regards to PPE to see an example of best practices. APPENDIX "D" provides two examples of minimum usage best practices for organizations that are regarded as being industry leaders in Occupational Health and Safety.

RECOMMENDATIONS:

8. The Directors of Investigations should mandate a documented site safety assessment. The site safety assessment should identify hazards that would allow Investigators to assess minimum PPE requirements for persons on site.

9. The Directors of Investigations should enforce the use of appropriate PPE as per the policy.

10. The TSB National OSH Policy Committee should amend the existing OSH PPE standards to include minimum PPE requirements for accident investigation sites.

4.3.6 EMPLOYEES GENERALLY MAINTAIN THEIR EQUIPMENT IN GOOD CONDITION AND ASK FOR REPLACEMENT ITEMS WHEN NEEDED, HOWEVER, SOME EQUIPMENTS HAD STALE DATES AND NO DATE RECORDS ARE MAINTAINED.

To determine if PPE is in good working condition, the auditors reviewed PPE inventory at each location they toured as well as reviewing a sample of employee PPE for each mode throughout the regional offices. Based on a visual inspection, the PPE appears to be well maintained. Managers and employees both indicated that they request replacement items when required and that, as a rule, the TSB employees are well equipped with PPE. However, there are no equipment replacement records and other than respirators, there is no evidence that expiration dates or "stale" dates are monitored. Additionally, the interviews suggest that maintenance of equipment is widely regarded as an individual responsibility. In the Richmond shop area, the auditors found Self Contained Breathing Apparatus (SCBA) with a stale date of April 2005. This equipment should be disposed of. It is a requirement of the Canada Labour Code for an employer to have equipment maintenance records. Having stale or unusable equipment increases the risk of injuries for staff.

RECOMMENDATION:

11. Managers should institute an annual process requesting that employees review the PPE that they have been issued and provide a declaration that the equipment is in good working order.

4.3.7 MOST OF THE PPE CURRENTLY IN USE MEETS THE SPECIFICATIONS STIPULATED IN THE TSB PPE STANDARDS

Based on a visual review of PPE the auditors found that the equipment meets the specifications as stipulated. However, a review of purchase documents for the last two years, indicated that equipment purchased by Head Office meets the specifications but there is no documentation to confirm that items purchased individually (safety footwear) meets the specifications stipulated in the standard. The only document that is required when employees purchase their own PPE is a receipt for proof of purchase. There is nothing to verify that the purchase meets the safety specifications. The risk is that TSB may be paying for comfort footwear rather than safety footwear. Further, if an employee wears the footwear purchased locally and it does not meet the safety specifications, there is risk of injury to the employee.

RECOMMENDATION:

12. To ensure that PPE in use meets the specification 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.


BEST PRACTICES1

Best Practices - OSH Training Program

All employees, including supervisors need to know about the workplace hazards to which they may be exposed. They need to know how to recognize the hazards and how to control their exposure. In the case of TSB, there are those hazards that exist on a day to day basis in the working environment that should be identified and documented. However, there are also the hazards that are unique to each accident site. These hazards should also be documented so that appropriate OSH training and PPE can be identified.

The following common key elements to a good Occupational Health and Safety training program include:

  • A written policy
  • Documented analysis of tasks and hazards requiring training
  • Selection of training specific to the hazards/tasks
  • Orientation for new employees covering workplace safety rules, hazards and employee requirements
  • Identification of training facilities/persons that can provide the required training
  • Training should be delivered in a way appropriate for comprehensive learning - drills, classroom sessions, hands-on, etc.
  • Individual training records including type of training, dates, and who provided the training
  • Enforcement, observation, and feedback to ensure training is meeting the needs identified

Best Practices - PPE

After researching several companies and organizations we have found the following common key elements of a good PPE program include:

  • A written policy
  • Documented analysis of tasks and hazards requiring PPE
  • Selection of appropriate PPE for the hazards identified
  • Written PPE requirements by Task/Hazard
  • Detailed PPE Standards
  • Purchase/inventory of PPE
  • Directions on Care, inspection and storage of PPE
  • Employee Training on use of PPE
  • Recordkeeping of Employee PPE
  • Enforcement, observation, and feedback to ensure proper use of PPE

CRITERIA FOR EACH AUDIT OBJECTIVE

Objective 1 - Compliance with Canada Labour Code and Treasury Board Policies

  • The TSB OSH training standards fully meet the requirements of the Canada Labour Code.
  • The TSB OSH training standards fully meet the requirements of the Treasury Board policies.
  • The TSB personal protective equipment standards fully meet the requirements of the Canada Labour Code.
  • The TSB personal protective equipment standards fully meet the requirements of the Treasury Board policies.

Objective 2 - Implementation of TSB OSH Training Standards

  • Managers and employees are familiar with the TSB OSH training standards.
  • Managers ensure that required training is included in training plans and that employees complete the required training within the prescribed timeframe.
  • Managers have access to complete, accurate, timely, detailed information on OSH training of their employees.
  • Managers ensure that recurring training requirements are met on a timely basis.
  • Employees are aware of their responsibilities and they do not undertake work or expose themselves to situations for which they have not been properly trained.

Objective 3 - Implementation of TSB Personal Protective Equipment Standards

  • Managers and employees are familiar with the TSB personal protective equipment standards.
  • Managers ensure that required equipment is provided to all employees on a timely basis.
  • Managers have access to complete, accurate, timely, detailed information on personal protective equipment for their employees.
  • Employees are aware of their responsibilities and they do not undertake work or expose themselves to situations for which they do not have the appropriate protective equipment.
  • Employees make proper use of the protective equipment provided to them.
  • Employees maintain their equipment in good condition and ask for replacement items where needed.
  • The personal protective equipment currently in use meets the specifications stipulated in the TSB personal protective equipment standards.

AUDIT STEPS

The audit program was developed and executed in the following manner:

  1. To determine if employees had received all of the mandatory and recurring training in the prescribed timeframe we reviewed various records for a random and a judgemental sample of employees. These records included: employee training files maintained by Human Resources, employee training files maintained by the Air, Marine, Rail & Pipeline mode, and Operational Services Branch, employee information in HRIS, and employee training spreadsheets maintained by the Lab and Regional offices.
  2. To validate whether training is included in annual training plans, we reviewed employee training spreadsheets as well as training budgets in the Regions, the Lab, and all of the Modes.
  3. To determine whether managers have access to accurate, detailed and timely reports on OSH training for their employees we used information from the interview and questionnaires, reviewed spreadsheets maintained by the Modes and the Operational Services Branch, and reviewed reports available in HRIS.
  4. To determine if managers provided PPE on a timely basis, that the equipment is maintained and replaced when needed, and that the PPE currently in use meets the specifications listed in the standards, we reviewed various records for a random sample of employees. These records included: PPE request forms, binders with individual employee request and issue dates, PPE inventory records, and procurement documents. We also randomly selected PPE for visual inspection at each location we visited
  5. To determine whether managers have access to accurate, detailed and timely reports on PPE for their employees we used information from the interviews and questionnaires, reviewed spreadsheets maintained by the Modes and the Operational Services Branch, and reviewed records maintained by the Manager of Finance and Administration.
  6. To determine if employees make proper use of the protective equipment provided to them we relied on information gathered in interviews and questionnaires and reviewed investigation photographs and site safety notes in TIIMS for a random sample of investigations. In addition we spoke to the IIC of the investigations in the sample. Other sources of information reviewed to validate this audit criteria include: TSB accident reports for the last three years, National OSH policy committee meeting minutes for the last three years, and the Air France Audit report.

MINIMUM PPE REQUIREMENTS

ARCELORMITTAL DOFASCO INC.

PERSONAL PROTECTIVE EQUIPMENT

General Requirements

The personal protective equipment necessary for each business unit will be discussed at and stated on the Safe Work Permit Meeting Form. It will also be specified on the Business Unit Site Specific document. Specific or additional protection for the work being performed must be evaluated by the third party employer.

All personal protective equipment deemed necessary by either ArcelorMittal Dofasco and/or the Third Party employer to protect the health and safety of the third party employee(s) is to be supplied by the third party employer.

As a minimum, the following personal protective equipment is required in all ArcelorMittal Dofasco plant areas (unless specified otherwise)

  • CSA approved Hard Hat (minimum Type 1 top impact)
  • CSA approved High Impact Safety Glasses (with permanently attached side shields) - whether prescription or non-prescription.
  • CSA approved Safety Boots (Grade 1 or Green Patch) - shoes are not permitted (some areas or some tasks may require additional metatarsal guards)
  • Long sleeved shirts and long pants

All personal protective equipment must be inspected regularly and be in a condition that2 provides the protection.

Do NOT Wear

There are also a number of items which may NOT be worn in any ArcelorMittal Dofasco plant areas:

  • Contact lenses
  • Finger rings
  • Loose or torn clothing (to avoid possibility of unintentional entanglement)
  • Dangling jewellery
  • Long hair (must be confined - tucked up inside hard hat)

WORKSAFE BC - FIRE FIGHTERS

3

Personal Protective Clothing and Equipment

31.10 General requirement

Firefighters must wear personal protective clothing and equipment appropriate to the hazards to which they may be exposed.

31.11 Maintenance
  1. The employer must have written procedures for the inspection of protective clothing and equipment at regular intervals.
  2. Procedures for cleaning and drying protective clothing must in accordance with the manufacturer's instructions.
  3. Defective items of protective clothing or equipment must be repaired or replaced.
31.12 Firefighter responsibility

Firefighters must ensure that the personal protective clothing and equipment used by them is maintained in good condition.

31.13 Safety headgear
  1. Safety headgear must be worn by firefighters required to approach the seat of a fire or enter a structure or other hazardous area during an incident.
  2. Safety headgear must meet the requirements of NFPA 1972, Helmets for Structural Firefighting: Structural Fire Fighters Helmets, 1992 Edition.
  3. Headgear meeting the requirements for safety headgear in Part 8 (Personal Protective Clothing and Equipment) may be used by firefighters
    1. while determining the cause of fires, or carrying out duties associated with preventing fires, or
    2. at the discretion of the incident commander, while fighting a fire in vegetation that is not within a structure.
31.14 Protective coats, pants and hoods

Firefighters required to approach the seat of a fire or enter a structure or other hazardous area during an incident must wear protective coats, pants and hoods meeting the requirements of

  1. NFPA 1971, Protective Clothing for Structural Fire Fighting, 1991 Edition, or
  2. CGSB Standard CAN/CGSB-155.1-M88, Firefighters' Protective Clothing for Protection Against Heat and Flame.
31.15 Station wear and personal garments

Firefighters required to approach the seat of a fire or enter a structure or other hazardous area during an emergency incident must not wear shirts, trousers, jackets or coveralls that have poor thermal stability or that ignite easily.

31.16 Working gloves

Firefighters required to approach the seat of a fire or enter a structure or other hazardous area during an emergency incident must wear gloves meeting the requirements of NFPA 1973, Gloves for Structural Fire Fighting, 1988 Edition.

Note: See Part 19 (Electrical Safety) for personal protective equipment and other safety measures required for work involving electrical hazards.

31.17 Fall protection
  1. A firefighter working on an aerial ladder must wear a safety belt and lanyard meeting the requirements of CSA Standard Z259.1-95, Safety Belts and Lanyards, and the securing lanyard must limit a fall to no more than 30 cm (12 in).
  2. A firefighter located on an aerial platform must wear a full body harness and lanyard meeting the requirements of Part II (Fall Protection).
  3. Rescue ropes, rappelling lines and safety belts and harnesses including safety hooks, rope grabs, lowering devices, and related equipment must meet the requirements of NFPA 1983, Fire Service Life Safety Rope, Harness and Hardware, 1990 Edition.
  4. The incident commander may depart from the requirements of Part II (Fall Protection) to use a fall protection system if, in the incident commander's opinion, such compliance is not practicable or may create a greater hazard, but subsections (1) to (3) of this section must be complied with.
31.18 Personal alert safety system
  1. A firefighter must be provided with and use a Personal Alert Safety System (PASS) when involved in duties which require a self-contained breathing apparatus to be worn.
  2. A PASS device must meet the requirements of NFPA 1982, Personal Alert Safety Systems (PASS) for Fire Fighters, 1993 Edition.
  3. A PASS device must be tested at least weekly and prior to use.

Respiratory Protection

31.19 General

Firefighters who may be exposed to an oxygen deficient atmosphere or to harmful concentrations of air contaminants must wear a self-contained breathing apparatus of a positive pressure type having a rated minimum duration of 30 minutes.

31.20 Fitness to use SCBA

A physician's certificate of fitness to use self-contained breathing apparatus must be provided to the employer by a firefighter who

  1. experiences breathing difficulty while using the apparatus, or
  2. is known to have heart disease, impaired pulmonary function, or any other condition that might make it dangerous for the firefighter to use self-contained breathing apparatus.
31.21 Operation of SCBA

Respirators must be used in accordance with CSA Standard CAN/CSA-Z94.4-02, Selection, Use, and Care of Respirators, Clause 9.1.

31.22 Sealing and fit testing
  1. Firefighters who use a self-contained breathing apparatus must be clean shaven to ensure that the mask forms a positive seal against the face.
  2. Fit tests must be performed in accordance with procedures in CSA Standard CAN/CSA-Z94.4-02, Selection, Use, and Care of Respirators.

    (2.1) A fit test must be carried out

    1. before initial use of a respirator,
    2. at least once a year,
    3. whenever there is a change in respirator face piece, including the brand, model, and size, and
    4. whenever changes to the user's physical condition could affect the respirator fit.
  3. Personal protective equipment that is worn with self-contained breathing apparatus and might interfere with a proper fit must be worn during the fit test.
  4. Only corrective eyewear designed for use with self-contained breathing apparatus may be worn.
31.23 Entry into buildings
  1. When self-contained breathing apparatus must be used to enter a building, or similar enclosed location, the entry must be made by a team of at least 2 firefighters.
  2. Effective voice communication must be maintained between firefighters inside and outside the enclosed location.
  3. During the initial attack stages of an incident at least one firefighter must remain outside.
  4. A suitably equipped rescue team of at least 2 firefighters must be established on the scene before sending in a second entry team and not more than 10 minutes after the initial attack.
  5. The rescue team required by subsection (4) must not engage in any duties that limit their ability to make a prompt response to rescue an endangered firefighter while interior structural firefighting is being conducted.
31.25 Spare equipment
  1. When self-contained breathing apparatus are used, the employer must ensure there are at least 4 apparatus available.
  2. At least one spare compressed air cylinder, having a rated minimum duration of 30 minutes, must be maintained at full rated capacity and available for each self-contained breathing apparatus.
31.26 Maintenance and records
  1. Self-contained breathing apparatus, including regulators, must be serviced and repaired by qualified persons.
  2. Inspection of compressed air cylinders must be done in accordance with CSA Standard CAN/CSA-Z94.4-02, Selection, Use, and Care of Respirators.
  3. Compressed air cylinders must be hydrostatically tested in accordance with CSA Standard CAN/CSA-B339-96, Cylinders, Spheres, and Tubes for the Transportation of Dangerous Goods.
  4. Complete maintenance and repair records for each self-contained breathing apparatus and all air cylinders must be kept in accordance with the requirements of CSA Standard CAN/CSA-Z94.4-02, Selection, Use, and Care of Respirators (section 10.3.3.2.2-b to f, inclusive).

  1. Best Practices compiled from Maine Labour, WorkSafe BC, Canadian Centre for Occupational Health & Safety, National Institute for Occupational Safety & Health.
  2. ArcelorMittal Dofasco Inc. Third Party Health, Safety & Environment Manual, Revised March 25, 2009, pg 42.
  3. WorkSafe BC - Fire Fighters