Audit of Occupational Health and Safety

Background

Aboriginal Affairs and Northern Development Canada (AANDC or "the Department") is one of the federal government departments responsible for meeting the Government of Canada's obligations and commitments to First Nations, Inuit and Métis, and for fulfilling the federal government's constitutional responsibilities in the North. The Department is divided into nine sectors and ten regions, and has a diverse workforce that spans across the nation. The business operations include a variety of occupations, some of which involve exposure to various hazards.

This report presents the findings of the AANDC Audit of Occupational Health and Safety. The decision to conduct the audit was identified in the Department's 2014-2015 to 2016-2017 Risk-Based Audit Plan and approved by the Deputy Minister on February 6, 2014. The audit focused on Occupational Health and Safety (OHS) management practices at AANDC'S Headquarters and included three regional site visits to Ontario, Alberta, and Nunavut. AANDC must adhere to federal OHS legislation, including the Canada Labour Code, Part II, and the Canada Occupational Health and Safety Regulations. Treasury Board (TB) has also established a Policy on Occupational Health and Safety and an Occupational Health and Safety Directive. The TB OHS Directive aims to complement the OHS programs found in federal departments and agencies and includes very specific safety and hazard prevention requirements. Both the CLC Part II and the TB Directive are intended as minimum standards that should be complemented by an employer's own OHS policies and procedures.

Audit Objective and Scope

The objective of the audit was to provide assurance on the adequacy and effectiveness of the system of management controls in place to support AANDC's OHS program and to ensure compliance with relevant legislation, regulations and policies. The audit did not seek to obtain assurance that employees consistently work in a safe manner or that workplaces are free of unreasonable hazards; however, point-in-time observations were made of workplaces and work practices in the regions selected for examination.

The audit scope included key elements of AANDC's OHS management control framework, including OHS governance, roles and responsibilities, OHS objective and priority setting, planning, risk-based hazard prevention, OHS committee operations, and the OHS-related activities of OHS professionals, managers, supervisors and employees. The audit focused on OHS management practices at AANDC's Headquarters and within the regions of Ontario, Alberta and Nunavut for the period April 2012 to September 2014. The audit did not examine federally regulated activities and operations regarding management liability for OHS incidents within First Nation communities.

Statement of Conformance

The audit conforms to the Internal Auditing Standards for the Government of Canada, as supported by the results of the quality assurance and improvement program.

Observations

In response to AANDC's 2009 Audit of Occupational Health and Safety, AANDC has made improvements in its OHS program. The Department has developed a comprehensive OHS Program Manual, describing OHS roles and responsibilities; increased its capacity through the addition of dedicated OHS personnel; and improved the operations of local OHS committees. These changes have led to improvements in the Department's conformance to OHS regulatory and policy requirements in some regions.

Notwithstanding improvements made to the OHS program in recent years, opportunities for improvement exist at the national level and in all regions visited. There is limited measurement of OHS program performance in regions and nationally, limited formal reporting to management on OHS program effectiveness and very little monitoring of OHS program implementation. While a very limited number of workplaces and programs (e.g., Northern Contaminated Sites Program) have implemented risk-based OHS hazard prevention programs, there is a general lack of occupational hazard identification and assessment, few hazard prevention programs and very little hazard-specific training. Improving these practices will further strengthen AANDC's OHS program, improve the organization's safety culture, and help to reduce safety incidents.

Conclusion

The audit found that the AANDC OHS program is partially effective with some opportunities for improvement. While the AANDC OHS program and capacity of the OHS organization have improved since the 2009 Audit of OHS, continued improvements are required in the areas of OHS priority setting and planning, hazard-focused OHS training, hazard-focused preventive measures, compliance of local and national OHS committees to legislative and regulatory requirements, and OHS program monitoring and reporting.

Recommendations

The audit team identified areas where management control practices and processes could be improved, resulting in the following four recommendations:

1. The Director General, Human Resources and Workplace Services Branch, with the support of the National Policy Health and Safety Committee, should ensure that a comprehensive National Occupational Health and Safety (OHS) Plan, based on the results of a completed departmental hazard assessment, is developed and implemented. In addition, the Senior Assistant Deputy Minister, Regional Operations, and the Assistant Deputy Minister, Northern Affairs Organization, should ensure that all regions develop and implement regional OHS plans that: i) address national OHS priorities and ii) establish region-specific priorities aimed at regional hazards.
2. The Director General, Human Resources and Workplace Services Branch, should ensure that a departmental Occupational Health and Safety (OHS) performance dashboard that tracks progress against key performance indicators (leading and lagging) and national OHS program priorities is developed. This information should be reported to senior management and the National Policy Health and Safety Committee at regular intervals to inform their oversight of the OHS program. Further, OHS performance dashboards and region-specific program deficiencies should be reported to Regional Directors General and Workplace OHS Committees at least annually.
3. The Director General, Human Resources and Workplace Services Branch, should ensure that a program is put in place for all managers and supervisors with responsibility for employees exposed to occupational and workplace hazards receive training on developing, implementing and maintaining hazard prevention programs. Further, the DG HRWSB should perform periodic reviews of the implementation of hazard prevention programs and highlight deficiencies to departmental senior management and the National Policy Health and Safety Committee as well as to responsible Assistant Deputy Ministers and/or Regional Directors General.
4. The Director General, Human Resources and Workplace Services Branch, should ensure that all Assistant Deputy Ministers and internal services branch heads develop and implement hazard prevention programs for their respective areas, including formal identification and assessment of workplace hazards, formal safety training programs, and preventive and protective safety measures. Workplaces and occupations with the greatest exposure to hazards should receive immediate attention.

Management Response

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

1.1 OHS Regulatory and Policy Context

The governance of OHS at AANDC occurs within a complex legislative, regulatory and policy framework. It is the policy of the federal government to provide employees with a safe and healthy working environment. The CLC Part II outlines the legislative framework and the duties and responsibilities of the employer and employees pertaining to OHS. Each duty outlined in the CLC Part II has a corresponding regulation prescribing specific requirements. As an employer, AANDC must adhere to this OHS legislation.

Treasury Board (TB) has a Policy on OHS and, in collaboration with bargaining agents and public service employers, established the National Joint Council OHS Directive. The OHS Directive aims to complement the OHS programs established in federal departments and agencies and includes very specific safety and hazard prevention requirements. Both the CLC Part II and the TB/NJC OHS Directive are intended as minimum standards that should be expanded on by a department's or agency's specific OHS policies and procedures. Per the TB Policy on OHS, federal departments and agencies must implement the requirements of the CLC Part II, maintain effective OHS programs, and provide training and information to employees. The elements of the TB/NJC OHS Directive are included in Exhibit 1 below.

1.2 AANDC's System of OHS Management Controls

AANDC's OHS Organization

The structure of the OHS organization at AANDC is composed of key groups, including the National Policy Health and Safety Committee (NPHSC), the Headquarters Security and OHS Division (SOHSD), three regional Human Resources (HR) Service Centres, Workplace OHS Committees, and OHS Representatives. A depiction of AANDC's OHS organizational chart is depicted in Exhibit 3 below.

Text alternative for Exhibit 3: AANDC OHS Organizational Structure

Exhibit 3 illustrates the OHS organizational structure at AANDC. At the highest level of AANDC’s OHS Organizational Structure is the Deputy Minister, who oversees direct reporting from the Director General, HRWSB and RDGs/ADMs. Under the umbrella of the Director General, the HRWSB includes the Director of Security OHS Division (SOHSD) and the Director of HR Service Delivery and Data Integrity. The RDGs/ADMs oversee direct reporting from their Managers and Supervisors, who have a direct reporting relationship with their employees.

The Director of SOHSD receives direct reporting from the Manager of OHS while the OHS Program Advisor of HQ and OHS Administrative Officer for HQ report to the Manager of OHS. At an organizational level, SOHSD supports the activities of the National Policy Health and Safety Committee (NPHSC), which escalates matters to the Deputy Minister as required.

The Director of HR Service Delivery and Data Integrity has a direct reporting relationship with the Regional Director HR Service Centre, whose subordinates are the PE Manager and OHS Administrative Officers for Regional Hubs.

From a functional perspective, at a regional/local level, employees report OHS issues and concerns to their local workplace OHS committee. Regional OHS Administrative Officers collect information regarding meetings/inspections/injuries from local workplace OHS Committees and communicate the information/reports to the Manager of OHS at HQ. Local workplace OHS committees also provide regular reporting to their senior management.

The diagram also depicts the direct and functional inter-relationship between each level, identified as 1 to 6 on the exhibit.
The following are the functional relationships:

• #1: between Deputy Minister and NPHSC;
• #2: between RDGs/ADMs and Local Workplace Health and Safety Committees;
• #3: between Employees and Local Workplace Health and Safety Committees;
• #4: between Local Workplace Health and Safety Committees and OHS Administrative Officers;
• #5: between OHS Administrative Officers and Manager OHS; and,
• #6: between Director SOHSD and NPHSC.

 

- - Dashed Line: Indicates Functional Relationship

1. The NPHSC reports to the Deputy Minister and escalates OHS issues where necessary
2. Local workplace OHS committees provide regular reporting to senior management. For HQ-based ADMs and DGs, only two have local workplace OHS committees reporting to them because committees are attached to physical locations and not organizational structure
3. Employees report OHS issues and concerns to their local workplace OHS committee
4. Regional OHS Administrative Officers collect information regarding meetings/inspections/injuries from local workplace OHS Committees
5. Manager OHS at HQ collects information and communicates with regional OHS Administrative Officers
6. The SOHSD supports the activities of the NPHSC, and the NPHSC escalates matters to the DM as required

 

As part of the Department's implementation of the Deficit Reduction Action Plan (DRAP), announced in the 2012 Federal Budget, regional human resource functions previously located in the ten regional offices were consolidated into three regional Human Resource (HR) Service Centres. These HR Service Centres are located in Edmonton (servicing the British Columbia, Alberta, Saskatchewan and Yukon regions), Toronto (servicing the Manitoba, Ontario and Northwest Territories regions), and Québec City (servicing the Québec, Nunavut and Atlantic regions). The regional HR Service Centres provide advice, guidance, and support regarding regional OHS matters to managers, employees, OHS Committee members and OHS representatives. As a result of DRAP, AANDC has introduced three full-time OHS Administrative Officer (AS-03) positions, one in each of the three HR Service Centres. The role of these OHS Administrative Officers is to provide support for the implementation of the OHS program.

The operations of the OHS program are largely decentralized, where the management and implementation of the program is delegated to regional offices with some support from the SOHSD and the OHS Administrative Officers in the HR Service Centres. The SOHSD provides functional direction, information and advice on national legislation, administrative and health matters to management, employees, HR Service Centres and OHS Administrative Officers. In keeping with the AANDC OHS Policy requirements senior management assumes the responsibility for ensuring the development, implementation, and monitoring of the OHS program at all departmental workplaces. Ultimately, Regional Directors General and Sector Assistant Deputy Ministers are accountable for managing and overseeing OHS programs within their respective areas.

AANDC has established the NPHSC in accordance with the requirements of the CLC Part II and the TB/NJC OHS Directive. The NPHSC's mandate is to provide national leadership, strategic direction and support to regional and local committees, and serves as the national forum for union/management consultation and problem solving for health and safety in the workplace.

The NPHSC participates with management in the development and monitoring of health and safety programs established by the Department to ensure compliance with the governing legislation and ensures employees are fully aware of and understand OHS. NPHSC addresses issues that have a department-wide impact, including the development, review and oversight of policies and programs, work process, and procedures. The OHS Manager, within the SOHSD, liaises between OHS Administrative Officers and the NPHSC in the monitoring and implementation of the OHS program.

The establishment of local Workplace OHS Committees is outlined in the Commitment and Accountability chapter of the OHS Program Manual. AANDC has established a number of Workplace Health and Safety Committees in compliance with the CLC Part II, which requires a local committee in each workplace with 20 or more workers. Employees sitting on OHS committees are required to receive training and allotted time for participation in meetings and carrying out their duties. For workplaces with less than 20 employees, an OHS Representative (an employee that does not exercise managerial functions) must be appointed in lieu of establishing a local OHS committee.

2.1 Audit Objective

2.2 Audit Scope

The audit examined key elements of AANDC’s system of OHS management controls, including:

• Design of OHS governance processes and appropriateness of OHS-related roles and responsibilities;
• Adequacy of OHS objective setting, priority setting and planning activities;
• Appropriateness of risk-based hazard prevention programs put in place for higher-risk occupations and workplaces;
• Adequacy of supports made available to OHS committee members, OHS professionals, managers, supervisors and employees to enable them to fulfill their OHS roles and responsibilities;
• Effectiveness of the national and regional OHS committees, including compliance to related legislative and regulatory requirements;
• Adequacy of controls for monitoring and measuring OHS program implementation; and,
• Improvements made to the OHS program as a result of the 2009 internal audit.

The audit focused on OHS management practices at Headquarters and within the regions of Ontario, Alberta and Nunavut for the period April 1, 2012 to September 30, 2014. The audit work conducted in the Ontario and Alberta regions included an examination of three federally operated schools, two in Ontario and one in Alberta. The audit also examined compliance with the CLC Part II and AANDC’s OHS program requirements. The audit did not examine federally regulated activities and operations regarding management liability for OHS incidents within First Nation communities.

5.1.1 Commitment, Leadership and Employee Participation

Management commitment and leadership, and effective worker participation are crucial to the success of a sound OHS management program. This includes leadership over OHS activities and senior-level assumption of overall responsibility for the system of OHS management controls. It also includes the designation of one or more representatives of management who, irrespective of other responsibilities, have defined roles, responsibilities, and authority for ensuring that an OHS management system is established, maintained, and reviewed. All of this should be done in consultation with employees.

At AANDC, OHS operations are largely decentralized with some support from the Headquarters OHS Division (SOHSD) and OHS Administrative Officers in the regional Human Resource (HR) Service Centres. Ultimately, Regional Directors General and Assistant Deputy Ministers have responsibility for managing and overseeing OHS programs within their respective organizations.

The AANDC OHS Program Manual describes the OHS roles and responsibilities from the level of the Deputy Minister down to supervisors and employees. In the case of the Assistant Deputy Ministers, Regional Directors General and Directors General, the policy requires that they provide leadership in the effective implementation and monitoring of OHS within their areas of responsibility. For all regions examined, there were limited levels of regional senior management involvement in the OHS program, including program planning, OHS communications and awareness activities, and OHS program oversight. Further, in all regions examined, we observed that local OHS Committee members are assuming some of management's responsibilities for addressing gaps in the regional OHS programs. The CLC Part II and its associated regulations establish that workplace committees play a monitoring and advisory role; they are not mandated to support implementation of OHS programs and initiatives.

In all of the regions examined, managers interviewed described their involvement in Workplace OHS Committees as being largely reactive to issues and concerns brought forward by Committee members and staff. Our review of OHS documentation corroborated this. There is minimal proactive OHS planning that occurs at the regional and Workplace OHS Committee levels, and only one of the four Committees observed had an annual committee work plan.

It was observed that workplace OHS Committee members have generally assumed primary responsibility for addressing OHS issues and concerns that arise including those identified through workplace inspections and developing local worksite OHS procedures. Almost all Workplace OHS Committee employee representatives interviewed reported that OHS is an add-on to their existing full-time workload and that they felt they needed more time to fulfill their OHS Committee responsibilities.

A higher level of OHS program implementation was observed in regions where the OHS Administrative Officers are physically located. This extra layer of support for the Workplace OHS Committees has lessened the workload for committee members; however, the OHS Administrative Officer capacity does not allow them to assist on all areas of responsibility of the Workplace OHS Committee and OHS program. Of the three full-time OHS Administrative Officer positions in regional HR Service Centres, one is presently vacant (in the position at the Western-Yukon HR Service Centre). The OHS Program Advisor (AS-04) position within SOHSD is also presently vacant.

5.1.2 OHS Program Planning

In a well-functioning OHS program, a formal planning regime is in place to identify and prioritize OHS-related hazards, risks, legal requirements, and OHS program deficiencies. The CLC Part II reinforces that proper planning is a key element of an effective Hazard Prevention Program (HPP), which is discussed in more detail later in this report. The Canada Occupational Health and Safety Regulations further establish that an effective HPP should include an implementation plan, hazard identification and assessment methodology, hazard identification and assessment, preventive measures, employee education, and periodic review. An effective OHS planning process should include the establishment of appropriate objectives and targets, and cascading plans to achieve compliance with legal and policy requirements. Hazard and risk assessments are the foundation for OHS planning, ensuring that policies, preventive measures and training regimes are properly designed.

As outlined in AANDC's OHS Program Manual, the national OHS Manager within SOHSD is responsible, in consultation with the NPHSC, for administering the HPP. Managers throughout the Department are responsible for implementing hazard and risk-based preventive measures and training regimes.

Further, CLC Part II requires that AANDC develop, implement and monitor, in consultation with the NPHSC^{Footnote 3}, a prescribed program for the prevention of hazards in the workplace appropriate to the size and nature of the hazards in it. Hazard identification and risk assessments were found to be inadequate in all regions visited, with only one out of three regions examined having completed formal hazard assessments for some of its operations.

OHS-related plans from the NPHSC, SOHSD, HR Service Centres, OHS Administrative Officers and Workplace OHS Committees from across the Department were examined where available. We found that they were not well aligned, incomplete and did not focus on areas of greatest risk. Measureable OHS targets and objectives were not established and most Workplace OHS Committees had little to no OHS plans in place. This inadequate planning is contributing to a fragmented implementation of the OHS program and duplication of efforts across the Department.

Recommendation

1. The Director General, Human Resources and Workplace Services Branch, with the support of the National Policy Health and Safety Committee, should ensure that a comprehensive National Occupational Health and Safety (OHS) Plan, based on the results of a completed departmental hazard assessment, is developed and implemented. In addition, the Senior Assistant Deputy Minister, Regional Operations, and the Assistant Deputy Minister, Northern Affairs Organization, should ensure that all regions develop and implement regional OHS plans that: i) address national OHS priorities and ii) establish region-specific priorities aimed at regional hazards.

5.1.3 Performance Reporting, Oversight and Continuous Improvement

In a well-functioning OHS program, management reviews the organization's OHS program at planned intervals to ensure its continuing suitability, adequacy and effectiveness. The objective of these formal and informal reviews is to identify any needed changes to the OHS program and opportunities for continued improvement. These requirements are embedded throughout the CLC Part II and its associated regulations.

AANDC's OHS Program Manual notes that the responsibility for monitoring the implementation of OHS programs is assigned to the Director General, Human Resources and Workplace Services Branch (HRWSB). Assistant Deputy Ministers, Regional Directors General and Directors General are required to implement and monitor OHS programs within their respective areas of responsibility, while Directors, Managers and supervisors are required to implement and ensure conformance with applicable OHS policies, directives, procedures and guidelines.

The audit identified inadequate measurement and reporting of OHS performance at all levels of the Department. The SOHSD is in the process of implementing a performance measurement regime, including tools to collect OHS performance data and processes to feed this information to Headquarters. The audit highlighted data integrity issues with the information reported by regions, and the OHS Administrative Officers are proactively working to resolve these issues. Examples of issues noted are: incomplete or lack of tracking of committee activities and meetings, lack of logs to track incidents, and incomplete tracking and documentation pertaining to work-related injuries.

The audit identified limited information on the effectiveness of regional OHS program implementation being made available to regional management and the NPHSC. Regional Directors General were not aware of important indicators of non-performance and non-compliance, as they are not receiving the necessary information. Examples of deviations which are not being elevated to regional senior management include, workplace OHS committees not meeting their legislative requirements to conduct meetings at required intervals, low levels of OHS training in some workplaces, failure to resolve OHS issues raised through committee meetings in a timely manner, and OHS inspections not being completed.

In the absence of performance information and routine reporting to management, we concluded that monitoring and oversight of the effectiveness of OHS program nationally and regionally, including compliance with legislation and policy requirements, was inadequate. The audit identified opportunities to strengthen OHS governance and communications in the Department, as highlighted in the diagram below.

Text alternative for Exhibit 4 : AANDC Occupational Health and Safety Organizational Structure

This diagram also represents OHS organizational structure at AANDC. At the highest level of AANDC’s OHS Organizational Structure is the Deputy Minister, who oversees direct reporting from the Director General, HRWSB and RDGs/ADMs. Under the umbrella of the Director General, the HRWSB includes the Director of Security OHS Division (SOHSD) and the Director of HR Service Delivery and Data Integrity. The RDGs/ADMs oversee direct reporting from their Managers and Supervisors, who have a direct reporting relationship with their employees.

The Director of SOHSD receives direct reporting from the Manager of OHS while the OHS Program Advisor of HQ and OHS Administrative Officer for HQ report to the Manager of OHS. At an organizational level, SOHSD supports the activities of the National Policy Health and Safety Committee (NPHSC), which escalates matters to the Deputy Minister as required.

The Director of HR Service Delivery and Data Integrity has a direct reporting relationship with the Regional Director HR Service Centre, whose subordinates are the PE Manager and OHS Administrative Officers for Regional Hubs.

From a functional perspective, at a regional/local level, employees report OHS issues and concerns to their local workplace OHS committee. Regional OHS Administrative Officers collect information regarding meetings/inspections/injuries from local workplace OHS Committees and communicate the information/reports to the Manager of OHS at HQ. Local workplace OHS committees also provide regular reporting to their senior management.

The diagram also depicts the direct and functional inter-relationship between each level, identified as 1 to 6 on the exhibit.
The following are the functional relationships:

• #1: between Deputy Minister and NPHSC;
• #2: between RDGs/ADMs and Local Workplace Health and Safety Committees;
• #3: between Employees and Local Workplace Health and Safety Committees;
• #4: between Local Workplace Health and Safety Committees and OHS Administrative Officers;
• #5: between OHS Administrative Officers and Manager OHS; and,
• #6: between Director SOHSD and NPHSC.

This diagram also indicates where improved communication is required: i) between sectors/regional managers/supervisors and Local Workplace Health and Safety Committees ii) between Local Workplace Health and Safety Committees and Regional Hubs OHS administrative Officers iii) between regional OHS administrative officer and HQ OHS Manager, and, iv) between Director of the Security OHS Division and National Policy Health and Safety Committee.

Red Line: indicates where improved communication is required

- -  Dashed Line: Indicates Functional Relationship

1. The NPHSC reports to the Deputy Minister and escalates OHS issues where necessary
2. Local workplace OHS Committees provide regular reporting to senior management. For HQ-based ADMs and DGs, only two have local workplace OHS Committees reporting to them as committees are attached to physical locations and not organizational structures
3. Employees report OHS issues and concerns to their local workplace OHS committee
4. Regional OHS Administrative Officers collect information on meetings/inspections/injuries from local workplace OHS Committees
5. Manager OHS at HQ collects information and communicates with regional OHS Administrative Officers
6. SOHSD supports the activities of the NPHSC, and the NPHSC escalates matters to the DM as required

Recommendation

2. The Director General, Human Resources and Workplace Services Branch, should ensure that a departmental Occupational Health and Safety (OHS) performance dashboard that tracks progress against key performance indicators (leading and lagging) and national OHS program priorities is developed. This information should be reported to senior management and the National Policy Health and Safety Committee at regular intervals to inform their oversight of the OHS program. Further, OHS performance dashboards and region-specific program deficiencies should be reported to Regional Directors General and Workplace OHS Committees at least annually.

5.2 Implementation of the OHS Program

Implementation of the OHS program includes determining, establishing, and maintaining the infrastructure and resources needed to achieve conformity with legislative and policy requirements and ensure the protection of workers. This includes:

• Establishing and maintaining processes to implement preventive and protective measures that address identified hazards and risks (i.e. Hazard Prevention Programs);
• Ensuring that supervisors and employees are aware, trained and competent to implement the OHS program; and
• Maintaining the documents and records necessary to effectively implement the OHS program and assess conformance with legislative and policy requirements.

5.3 Occupational Health and Safety

The 2009 AANDC Audit of OHS identified the following ten recommendations:

1. OHS knowledge and competency requirements for all categories of managers and employees should be defined. Appropriately detailed instructional procedures should be developed. Training and instruction standards and programs should be established and implemented using a risk-based approach (i.e. higher hazard program areas and occupations) to ensure that personnel understand and can discharge their OHS roles and responsibilities.
2. Specific OHS governance requirements and procedures, applicable to Corporate and the Regions should be established for: (1) OHS objective setting, (2) development of formal plans to achieve objectives; (3) OHS auditing and evaluation; (4) OHS opinion surveys of the workforce; (5) internal reporting on the foregoing; and (6) senior management review of findings and recommendations arising therefrom. These requirements should be incorporated into the existing INAC OHS Statement of Roles and Responsibilities.
3. The scope of support to be provided to internal departmental clients by SOHS Directorate and other departmental HS resources, as well as the performance standards, mechanisms for delivering such support, resource requirements for success, and procedures for monitoring delivery and impacts should be developed.
4. A blueprint for future corporate OHS program development (policies, standards, and procedures), determining resource requirements, and obtaining senior management approval should be developed and implemented in consultation with the Policy HS Committee.
5. An enterprise information management system requirements and procedures to support department-wide HS management and record keeping should be assessed, specified and implemented.
6. Department-wide OHS programs, guidelines and procedures required for the higher risk operations carried out by departmental personnel should be identified, developed and implemented.
7. Procedures to ensure proper flow of information between SOHS Directorate, HR / HS Advisors, HS Representatives, and HS Committees should be established and implemented.
8. The selection and appointment of health and safety representatives at those additional locations where required should be conducted.
9. The need for additional HS specialist staff, and optimal organizational placement, to adequately support the organization should be assessed.
10. HRSDC approval of the existing HS committee structure, to avoid the need for creation of additional HS committees, should be obtained.

Of these 10 recommendations, six have been adequately addressed (#2, #4, #7, #8, #9 and #10) and three require continued focus to ensure that the OHS program is implemented and monitored effectively (#1, #3 and #6). One recommendation (#5) is no longer considered appropriate as it would have considerable cost implications and can be addressed through Excel-based tracking tools currently being rolled out by SOHSD.