Disclosure of internal audits 2009-2010

TSB Management Response and Action Plan
Internal Audit of OSH Training and PPE

TSB management accepts the findings of this audit and generally agrees with the recommendations made by auditors. The detailed management responses and actions planned are described in the following tables.

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.

Management Response

Management agrees that the PPE policy and standards need to be clarified.

Actions Planned

Review PPE policy and standards.

Update and clarify PPE maintenance, record keeping and obligations for persons granted access to occurrence sites, where necessary.

OPI

PPE Sub-Committee

Timeline

End of Fiscal Year 2010 / 2011.

Recommendation 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.

Management Response

Management agrees that new employees must be informed on TSB's OSH policies and that all employees be reminded on a regular basis of these policies.

Actions Planned

The new employee orientation session will be modified to remind employees of Management's responsibility to brief employees on OSH policies and requirements.

The new employee orientation session, which includes instructions on how to access TSB's Reference Centre where all policies are filed, will be delivered on an on-going basis.

The orientation checklist provided to new employees will be modified to include an item for briefing employees on OSH policies.

Annual reminders on OSH policies, as part of the OSH Safety Week, will be sent out to employees.

OPI

Manager of Human Resources / OSH National Policy Committee

Timeline

End of Fiscal Year 2010 / 2011.

Recommendation 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.

Management Response

Management agrees that a better monitoring and tracking tool for OSH training is required.

Actions Planned

Once the Training and Standards Division is created, this Division will work with Human Resources to identify and implement suitable systems to track and report on all training, including OSH.

The Training and Standards Division, in conjunction with the OSH National Policy Committee, will ensure that clear training standards for the required OSH training are established.

In the interim, a communiqué will be issued to managers and employees reminding them of their obligation to remain current on OSH training.

OPI

Manager of Training and Standards

Timeline

Fall 2011.

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.

Management Response

Management agrees that accurate information and training records must be captured and inputted into selected system.

The option selected for maintaining the OSH Training Records (see Recommendation 3) will influence how the records are entered and what documentation is maintained.

Actions Planned

When conducting the review of options for the OSH Training Monitoring System, the requirements identified in this Recommendation will be considered.

Where required and feasible, the appropriate functionality will be implemented into the selected system (see Recommendation 3).

Until a new system is implemented, HR will work with the RC Managers to ensure that OSH Training Forms are completed, approved and entered into the HRIS system by the Branch Administration Officer. A copy of the OSH Training Form will be sent to HR for entry verification and filing.

OPI

Manager of Human Resources

Timeline

End of Fiscal Year 2010 / 2011.

Recommendation 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.

Management Response

Management agrees that a site safety assessment should be documented for all occurrence sites.

Actions Planned

A Site Safety Assessment Form will be developed and implemented across all modes.

OPI

DOI - Air

Timeline

Fall 2010.

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.

Management Response

Management agrees that obsolete equipment must be disposed and inventory management practices need to be improved.

Actions Planned

Review, update and implement changes (if necessary) to the practices for maintaining a PPE inventory.

Remove and appropriately dispose of all expired PPE equipment and PPE equipment that no longer meets TSB requirements.

OPI

Manager of Finance / Administration

Timeline

Fall 2010.

Recommendation 7

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

Management Response

Management agrees that recordkeeping for PPE must be improved.

Actions Planned

Determine how this information is currently captured and maintained.

Develop and update guidelines for capturing and maintaining this information on a consistent basis across all TSB offices.

Notify RC Managers and Administrative Officers of the new policy guidelines.

OPI

PPE Sub-committee.

Timeline

End of Fiscal Year 2010 / 2011.

Recommendation 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.

Management Response

Management agrees that a site safety assessment should be documented for all occurrence sites.

Actions Planned

A Site Safety Assessment Form will be developed and implemented across all modes (see Recommendation 5).

OPI

DOI - Air

Timeline

Fall 2010.

Recommendation 9

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

Management Response

Management agrees that the use of appropriate PPE (as per the policy) must be enforced.

Actions Planned

Prepare and disseminate a communiqu� to all personnel that have been issued PPE regarding compliance to the use of appropriate PPE.

Develop guidelines on how to monitor for compliance to the use of appropriate PPE.

Develop guidelines on how to handle situations when appropriate PPE is not used.

OPI

PPE Sub-Committee

Timeline

End of Fiscal Year 2010 / 2011.

Recommendation 10

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

Management Response

Management agrees in principle that existing OSH PPE standards should include minimum PPE requirements for accident sites.

However, individual minimum PPE requirements may be developed for each mode if an overall consolidated minimum list cannot be identified.

Actions Planned

Refer to Actions Planned for Recommendation 1.

OPI

PPE Sub-Committee

Timeline

End of Fiscal Year 2010 / 2011.

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.

Management Response

Management agrees that a review of PPE (by employees) should be conducted and documented on a scheduled basis.

Actions Planned

Develop and implement an on-going process for employees to confirm and report annually that their PPE is in good working order.

The process will include information aids / checklists to ensure that the employees can determine whether their PPE is in good working order.

Training on the use of these information aids / checklists will be developed and implemented (if necessary).

OPI

PPE Sub-Committee

Timeline

End of Fiscal Year 2010 / 2011.

Recommendation 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.

Management Response

Management agrees that the procurement practice of allowing the purchase of standard PPE locally in non-urgent situations should be reviewed.

Actions Planned

Identify options to ensure that locally-purchased PPE equipment meet the required specifications.

Implement the preferred option.

Update and clarify (if necessary) guidelines for purchasing standard PPE by employees.

OPI

Manager of Finance / Administration

Timeline

Fall 2010.