The Workwell Audit
General Information and Explanation for Eng Phys / CEDT

G. Pearson
Posted: January 16, 2008
Last Updated: January 17, 2008

You've likely heard by now that in the spring of 2008 McMaster University's safety program will be the subject of an audit.

This "Workwell" audit is being conducted by the Workplace Safety and Insurance Board (WSIB) of Ontario.

The WSIB announced its intention to conduct the audit because in recent years McMaster has had an above average rate of Lost Time Injuries. The audit is intended to identify and correct any factors that may contribute to our high injury rate. The WSIB will be evaluating McMaster's safety program on 12 criteria, described below in Table 2 and detailed in the remainder of this page. If McMaster fails to achieve a rating of 75%, we will have 6 months to make improvements before a second evaluation. Failure to achieve a rating of 75% on the second audit could result in fines of up to $500 000.

TABLE 1: McMaster's Health and Safety Record

[From the presentation "Understanding Workwell," W. McKenna (Work-Life Support Services) and S. Fletcher (EOHSS), March 1, 2007]

More information concerning the audit is available from the EOHSS website, or via the "Workwell Resources" links in the box to the right above. The remainder of this page provides information for Engineering Physics and the CEDT on preparing for the audit.

How Are Eng Phys and the CEDT Preparing for Workwell?

Graham Pearson will be coordinating our efforts to prepare for the workwell audit during January through April of 2008. If our Faculty or Staff have questions or concerns, these can be directed to Graham at x26387.

Workwell evaluates McMaster on 12 criteria, each with a specific weighting, as indicated in the following table.

TABLE 2: Workwell Audit Sections

[From the presentation "Understanding Workwell," W. McKenna (Work-Life Support Services) and S. Fletcher (EOHSS), March 1, 2007]

In Table 2, the three sections highlighted in amber are those most relevant to Supervisors in Eng Phys and CEDT. This includes Faculty, Technical Staff, Adminstrative Staff with supervisory responsibilities, could include PDFs, and may to some extent include Graduate Students in their capacity as TAs.

Workwell emphasizes that safety programs should establish clearly defined responsibility. A major component is documentation hazard assessments, training, and standard operating procedures.

That is, Supervisors need to be conscientious in ensuring that hazards are identified and mitigated, and workers need to work in accordance with safe practices and report any new hazards. By formally documenting hazard assessments, training records, and standard operating procedures, there's far less likelihood that a hazardous situation or irresponsible behaviour might slip through the cracks in an organization. A clearly structured, organized documentation system is in everyone's interest.

A recurrent question at meetings and courses recently is "How do we know our documentation and record-keeping is sufficient?" The answers haven't been entirely clear.

Arguably Eng Phys and the CEDT are in reasonable shape, given that we provide general hazard awareness training to all new students and employees, and we have them prepare a hazard awareness report specific to their research or work, to be veted by their Supervisor. We also insist that labs and facilities be assessed for potential hazards and that these assessments are posted on the lab doors.

Despite these efforts, there remains some confusion as to whether we sufficiently comply with the applicable regulations and University programs that attempt to govern these matters. I'm working to clarify some of these concerns.

As such though, with Workwell on the horizon, please anticipate and forgive a certain amount of confusion as we attempt to get our housekeeping in order as it pertains to documentation and record-keeping. Bring any questions to my attention and I'll try to determine definitive answers.

In the remainder of this page I'll provide a breakdown of the Workwell Audit Sections from Table 2. Where a Section is applicable to Eng Phys or the CEDT, I'll provide some explanation and directions.

Workwell Section 1: Health & Safety Policy

McMaster's Health & Safety Policy is outlined in Risk Management Manual Program #100. The Faculty of Engineering posts a copy on their safety bulletin board in the lobby of JHE.

The Policy is also posted on the Eng Phys/CEDT safety bulletin board, outside of JHE A315, and on the Eng Phys/CEDT safety website.

The policy basically states that McMaster makes every reasonable effort to ensure a safe work environment. Supervisors are responsible for identifying, documenting, and mitigating potential hazards in their work areas. All parties (Supervisors and Employees, as well as students and visitors) must abide by the Supervisor's procedures and guidelines.

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Workwell Section 2: Health & Safety Responsibilities

The first of the three "big" sections for Eng Phys and the CEDT. Luckily, McMaster is already on top of communicating the breakdown of reponsibility, via RMM 100 in the previous section and via Due Diligence training. As such, you should already be well aware of your responsibilities, as well as those of the people working around you.

How Does Section 2 Apply to the Department?

The "Understanding Workwell" presentation indicates that documented performance evaluations for Managers and Supervisors should include health and safety issues.

How Does Section 2 Apply to Supervisors?

From RMM 100,

So basically, Supervisors are expected to take responsibility for their work area and the well being of all persons who they supervise or who visit their work area. This includes:

1. participating in Due Diligence Training and various other mandatory courses for supervisors,
2. making sure hazard assessments are completed for their work area,
3. making sure safe procedures are adopted,
4. training persons working under the supervisors care, and,
5. documenting the training you provide your staff and students.

How Does Section 2 Apply to Workers/Students?

From RMM 100,

That is, employees and students are responsible for working in a safe manner, in accordance with the training and procedures provided by their Supervisor.

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Workwell Section 3: Posted Health & Safety Materials

Certain documents, like the RMM 100 policy or MSDS sheets, need to be posted in certain places where they're easy to locate.

How Does Section 3 Apply to the Faculty?

The Faculty is mandated to post certain documentation on the safety bulletin board located in the foyer of JHE. This documentation includes:

1. the University's Health and Safety Policy (RMM 100),
2. a copy of Ontario's Occupational Health and Safety Act (OHSA),
3. a list of the members of the Faculty's Joint Health and Safety Committee (JHSC).

How Does Section 3 Apply to the Department?

Eng Phys and the CEDT are mandated by the Terms of Reference of the Faculty's JHSC to post certain documentation on our Departments' own safety bulletin board, located outside JHE A315. This documenation includes:

1. the University's Health and Safety Policy (RMM 100),
2. a copy of Ontario's Occupational Health and Safety Act (OHSA),
3. a list of the members of the Department's Health and Safety Committee.

Those are the basic materials, but then we've got this website. Hopefully the site points our people in the right direction on most of the Health and Safety topics commonly encountered by our department members.

How Does Section 3 Apply to our Supervisors?

Supervisors must post appropriate hazard awareness information in their areas.

This material should include:

1. a door poster, indicating hazards located in the lab and appropriate precautions,
2. a binder of MSDS sheets for any chemicals located in the workspace,
3. warning signs within the workspace to indicate hazards (e.g. lasers, radioisotopes, etc.),
4. standard operating procedures (SOPs) for operating potentially hazardous equipment or performing potentially hazardous procedures.

With regard to item 1 above, you probably already have a sign on your lab door stating what hazards are present within, and the sign should note appropriate precautions and emergency measures. The Departmental Safety Committee has been encouraging this for years now. A door hazard sheet template is available from the EP/CEDT safety website, also linked in the box at the right.

How Does Section 3 Apply to Students/Workers?

Students and Workers may need to post warnings or labels to ensure that any potentially hazardous conditions are known to others in the workspace. For instance, Students would be expected to label their chemicals or waste, etc., as should be normal practice.

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Workwell Section 4: Health & Safety Standards and Procedures

This is section is the most heavily weighted on the Workwell audit, and quite likely this is where most University departments would rate the weakest.

RMM Program #301 defines McMaster's guideline for standard operating procedures (SOPs).

RMM 301, Section 4.3, defines Standard Operating Procedures as "written procedures required by the OHSA under specific regulations and by McMaster University programs and policies, that define the techniques, processes and best practices required to prevent critical injury and/or occupational illness or damage to University equipment or the environment."

Paraphrasing slightly, a Standard Operating Procedure must be written for any process that has the potential to cause:

1. critical injury,
2. occupational illness,
3. damage to University equipment,
4. damage to the environment.

An immediate problem with these SOP criteria is subjectivity. Certain operations in Eng Phys or the CEDT obviously warrant SOPs, but in some cases it is likely much more difficult to determine if the procedure meets the criteria for an SOP. In addition, many tasks related to our research are "one-off" experiments and we might be inclined to neglect paper work. Not preparing an SOP could pose a serious failure of judgement should something go wrong.

Luckily SOPs need not be too onerous in most cases. You just need to show that you considered the relevant hazards and prepared for emergency contingencies.

How Does Section 4 Apply to Supervisors?

RMM 301 provides a guideline for writing SOPs, however, the guideline isn't very good and this may explain why SOPs seem to be poorly adopted.

The key points in developing an SOP are to:

1. Identify the SOP (Title, Author, Date Written, Supervisor Approval).
2. Identify the hazard to which the SOP applies, and describe potential dangers.
3. Document how to perform the work/procedure safely and properly.
   (e.g. how to start/operate/stop specific equipment, how to dispose of waste.)
4. Identify possible emergency contingencies should an accident happen.
   (e.g. Fire: alert others, pull alarm, vacate building. Spill: how to clean up and dispose of waste.)

It may also be appropriate to reference applicable regulations, RMM programs, etc. so someone reading the SOP can locate additional information.

The EP/CEDT Safety Committee is working on a template to simplify writing SOPs, but it may be some time before it's available.

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Workwell Section 5: Health and Safety Representative/Committee

The University needs to have both management staff and employee representatives participate in certain Joint Health and Safety Committees (JHSC). There's a Central JHSC, and also a Faculty JHSC.

The Faculty JHSC downloads some responsibilities to the Departments within Engineering. The Faculty JHSC requires that each Department have it's own safety committee to handle inspections and certain other duties.

How Does Section 5 Apply to the Department?

Eng Phys and the CEDT share a safety committee. The committee reports inspection results to the Faculty JHSC.

There has to be at least one Departmental Faculty member (management rep) on the committee, and there must be at least as many worker members as managerial members on the committee to maintain a favourable balance of decision-making power.

The Department also has to provide the worker members of the Department sufficient time to perform committee duties. The worker members of the committee do monthly inspections of the Department's facilities (usually assisted by the Department's managerial reps) so that the entirety of our facilities are inspected annually.

How Does Section 5 Apply to Workers?

Worker members of the department must sit on the Departmental safety committee. The worker members need to ensure the entire workplace is inspected annually, with at least a portion inspected each month.

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Workwell Section 6: Education and Training

McMaster University has an extensive training and orientation program, as outlined in RMM 300 (pdf). The University provides certain courses through EOHSS, and expects Supervisors to provide additional specific training to workers, students, visitors, or volunteers working in any given area.

Note that the most emphasized component of education and training is documentation of training completion. RMM 300 assigns these documentation responsibilities to Supervisors. Whether Eng Phys and the CEDT are entirely compliant is not absolutely clear at this time.

A guideline from RMM 300 for student/employee orientation and site-specific training is included in a potential documentation guideline at the end of this webpage.

How Does Section 6 Apply to Supervisors?

Section 6 applies to Supervisors in three ways:

1. Supervisors must ensure that their own training is up to date.
2. Supervisors must advise their workers/students/visitors of required training and ensure that this training is completed in a timely manner.
3. Supervisors must provide their workers/students/visitors with site-specific training for the equipment and operational procedures under their supervision. This site-specific training must be documented.

Regarding item 1, EOHSS has recently updated mandatory training requirements for Supervisors, as outlined in their mildly confusing "Corporate Training Matrix table. Supervisors in Eng Phys are now required to be up to date in:

• Asbestos Awareness
• Due Diligence - 3 year recert
• Fire Safety
• Lock Out/Tag Out (*not currently offered through EOHSS)
• Slips, Trips, and Falls (JHSC Cert)

Also, depending on your work or the work of those you supervise, you may be required to take additional training courses, including:

• Autoclave
• Bio Level 3 Training
• Biosafety
• Chemical Handling
• Confined Space
• Employee Health & Safety Orientation (Past, transferred, and mat leave)
• Fall Protection
• Fire Warden
• First Aid (Standard) - 3 year recert
• Fit Testing (? - SCBA masks)
• Forklifts - 3 year recert
• Golf Cart Safety
• Gas Cylinder
• Hydrogen Fluoride
• Indoor Air Quality
• JHSC Certification
• Ladder Safety
• Laser Safety - 2 year recert
• Machine Guarding Awareness
• Office WHMIS
• Property Protection
• Radiation Safety
• Self Contained Breathing Apparatus
• Specialized Biosafety A.F.
• Specialized TDG/Infect. Sub./Waste - 2 year recert
• Spills
• Transportation of Dangerous Goods - 3 year recert
• Violence in the Workplace
• WHMIS Core

I took the liberty of highlighting the courses that should pretty much be taken for granted as mandatory in Eng Phys. Note that conspicuously absent from the EOHSS list of courses marked as required is "electrical safety," but consider taking it when offered.

As per item 2 above, Supervisors must also make sure their subordinates participate in the appropriate training courses for any work conducted under the Supervisor's authority.

Finally, as per item 3 above, Supervisors must provide all persons in their work area appropriate site-specific training for the equipment operated and/or procedures conducted in their work area. This responsibility is obvious, and should already be in wide-spread practice within our labs and facilities. What is less obvious is how to provide satisfactory records of such site-specific training.

As mentioned earlier in this section, McMaster does provide certain guidelines for recording training, as outlined in RMM 300: Safety Training and Orientation Program. Again, whether Eng Phys and the CEDT are in complete compliance is not entirely clear at the moment.

How Does Section 6 Apply to Workers/Students?

In Eng Phys, students and workers are expected to complete a hazard assessment for their work area and any specific jobs in which they will be involved. The hazard assessment should be reported to their Supervisor, and will also be filed with the Departmental Safety Coordinator.

The hazard assessment will indicate if certain safety training courses should be taken. The Supervisor may assign additional training courses where appropriate.

Students and Workers and Engineering Physics and the CEDT are manditorily expected to participate in:

• Departmental Hazard Awareness training
• WHMIS training

Students and Workers must also be familiar with:

• the Laboratory Safety Handbook

Other training courses that may be highly applicable include:

• biosafety
• chemical handling
• chemical spills
• electrical safety
• ergonomics
• fire safety
• gas cylinder safety
• hydrogen fluoride safety
• laser safety
• radiation safety

See the EOHSS website for dates when these courses are offered.

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Workwell Section 7: First Aid Requirements

The OHSA madates that all employers must implement a First Aid Program, as laid out under Regulation 1101 of the Workplace Safety & Insurance Act.

Regulation 1101 requires that all employers must maintain first aid stations staffed by a first responder trained in Standard First Aid (a two day course). The stations must be located so that it takes no more than 4 minutes to get to one.

EOHSS is currently implementing Regulation 1101 throughout the McMaster campus. There will likely be two stations located on each floor of JHE and similar buildings.

Expect to hear more about the new first aid program in the near future.

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Workwell Section 8: Health & Safety Inspections

The University requires two types of workplace inspections:

1. Supervisors are expected to regularly inspect their own areas for safety hazards. It's prudent to record these inspections. (This came up at Due Diligence training, January 2008 - Probably such inspections are not formally occuring in EP/CEDT/University at the moment?)
2. As mentioned previously, the University's Central and Faculty JHSCs download responsibility to all Departments to conduct regular inspections of their areas mandated under the OHSA. These inspections must be conducted by worker members of the Departments. Inspection results are reported to the Faculty JHSC, which then reports to the Central JHSC.

Also note that in the event of a "critical injury" the Supervisor must immediately report the incident and ensure the area is cordoned off for a formal investigation.

Workwell Section 9: Preventative Maintenance

According to the WSIB's Workwell Information Package, they evaluate the workplace on its preventative maintenance program.

The criteria for this section include:

• inventory list
• standards to be met
• inspection schedule
• a standard recording system
• inspection by a qualified person
• review of program

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Workwell Section 10: Incident/Injury Investigations

Reporting and investigating injuries, incidents, and occupational disease is the subject of RMM Program 1000 (pdf).

How Does Section 10 Apply to Supervisors?

Injuries/incidents fall into two categories: "critical" injuries, and "non-critical" injuries/incidents.

"Critical Injuries" are serious incidents that result in bodily harm, and under OHSA regulations these must be reported immediately. Critical Injuries are to be investigated by a Certified Member of the relevant JHSC. In the event of a critical injury, once emergency aid has been provided to the victim(s) the area of the incident must be cordoned off for investigation.

Incidents or injuries that do not meet the definition of "critical" are to be investigated and reported to EOHSS by the supervisor with jurisdiction over the area where the incident occured.

Incident report forms are available from EOHSS and most campus offices, or can be downloaded (pdf) from the EP/CEDT safety site.

How Does Section 10 Apply to Workers?

In accordance with University Policy, Workers are expected to immediately report all incidents or unsafe conditions to their Supervisors.

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Workwell Section 11: Senior Management

This applies to University Administration.

Senior Management is expected to acknowledge its responsibility for matters related to establishing a safe and healthy workplace, and also to ensure that appropriate measures are in place.

At McMaster, Senior Management has EOHSS facilitate the University's health and safety program on Management's behalf, via the policy and programs outlined in the Risk Management Manual.

Obviously, various responsibilities are downloaded to Supervisors and Workers, as we touched on in Section 2 (Responsibilities) above.

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Workwell Section 12: Early and Safe Return to Work

As yet, I'm not sure about McMaster's programs in this area, but I expect that this is laid out through Human Resources. As such, EP/CEDT would just follow the protocol in the event that someone were to be returning from Long Term Disability leave.

A Potential Guideline for Documenting Hazard Assessments, Site-Specific Training, and SOPs.

Traditionally in Eng Phys, we've documented potential hazards in Faculty labs by generating a "Contact Information and Hazard Assessment" sheet, which has been posted on the door of each lab. In some cases instruction sets then accompany equipment or describe a particular process.

We've also provided general hazard training and associated documentation by ensuring that students and new employees attend "Hazard Awareness Training" and complete a "Hazard Assessment Report" specific to their research project, which is to be reviewed and signed by their Supervisor.

Whether these practices are entirely sufficient is currently the subject of some debate in Eng Phys, and certain revisions are under consideration. For instance, we would like to have students submit annual hazard reports, rather than a single report at the beginning of their course of study.

If anyone does feel inclined to go above and beyond the current Eng Phys/CEDT training and documentation program, I would suggest the following which incorporates guidelines extracted from RMM 300.

TABLE: A Potential Record Keeping Guideline for Supervisors

Details/templates to follow shortly....

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