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2005-728 Audit of PWGSC Compliance to DP 078 - Workplace Emergency Evacuation Plans, Final Report

September 8, 2006

Executive Summary
1. Introduction
2. Findings, Conclusions and Recommendations

Executive Summary

Objectives and Scope

The objective of the audit was to assess compliance with requirements for workplace emergency evacuation plans in buildings located in the National Capital Area (NCA) where the department owned, managed and was the primary tenant. These requirements are presented in the Canada Labour Code - Part II, Regulations Respecting Occupational Safety and Health Made Under Part II of the Canada Labour Code (CLC Regulations), Treasury Board of Canada Standard 3-1, Standard for Fire Safety Planning and Fire Emergency Organizations, and in Departmental Policy 078, Workplace Emergency Evacuation Plans (April, 2000).

The Audit & Ethics Branch initiated this audit in May 2005 in consultation with the Corporate Services, Human Resources and Communications Branch (CSHRCB) and the Real Property Branch (RPB), as well as with the Treasury Board Secretariat (Real Property and Materiel Policy and Safety, Health & Employee Services Directorates).

The audit was conducted from July 2005 to August 2005. It examined buildings in the NCA where the Deputy Minister of PWGSC has accountability for fire emergency evacuation plans covered by both the Treasury Board of Canada Standard 3-1 and PWGSC Departmental Policy (DP) 078. In the NCA, PWGSC owned, managed and was the primary tenant of nine buildings. The five largest buildings were selected for audit, representing a total of 4,244 PWGSC employees, or 98.6% of the total number employees occupying those buildings. The building examined were:

Place du Portage, Phase III (3,635 PWGSC employees);
King Edward Building (379 PWGSC employees);
Birks Building (142 PWGSC employees);
Plouffe Park (61 PWGSC employees); and
Conference Centre (27 PWGSC employees).

The audit objective did not include an examination of the impacts of utilizing Alternate Forms of Delivery service providers.

Audit Conclusion

PWGSC had compliance and control weaknesses with requirements for workplace emergency evacuation plans in the buildings selected for audit. There have been no adverse impacts.

Fire emergency evacuation plans, including building schematics and floor diagrams, did not contain much of the required information required by PWGSC DP 078. In particular, plans were deficient with regard to information on the identification and management control of fire hazards in the building.

With the exception of one building, evacuation or emergency drills were not conducted once a year, as required by PWGSC DP 078. Documentation of evacuation or emergency drill report content, as required by PWGSC DP 078 was generally insufficient and varied greatly in their consistent quality.

Although not a mandatory requirement, the audit found that building fire safety plans were often not prepared in cooperation with the fire department and were often not reviewed and signed by the senior officer responsible for the building. Even though the plans had been sent to HRSDC Labour Services, Fire Protection Engineering Services for review prior to implementation, the documents were old, in some cases, several years old and did not accurately reflect the current state of the buildings' fire emergency preparedness.

Three weaknesses in management control were also identified.

There are unresolved policy discrepancies between PWGSC's DP 078, TB Standard 3-1 and the CLC Regulations. Specifically, in the assignment of responsibility for preparing and maintaining fire emergency evacuation plans,. DP 078 assigns responsibility for a broader range of buildings than TB Standard 3-1. According to the Treasury Board Standard, PWGSC is responsible only for those buildings where the Department is the owner, occupant and primary tenant. TB Standard 3-1 requires PWGSC to submit fire safety plans to HRSDC Labour Services for review, while DP 078 does not make this requirement.
Officers responsible for preparing building fire emergency plans were not adequately aware of or understand the requirements and their responsibilities.
The deficiencies and the inconsistent practices found during the audit indicated a lack of corporate oversight and monitoring.

OAE debriefed CSHRCB and TBS on the detailed audit results. CSHRCB advised that, working in consultation with TBS, the Department is taking actions in response to the deficiencies identified.

Recommendations to the Assistant Deputy Minister, Corporate Services, Policy and Communications Branch are contained in the main body of the audit report.

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1 Introduction

1.1 Authority for the Project

1.2 Objective

1.3 Scope & Approach

The National Building Code of Canada (NBC) provides minimum requirements for health, life safety and structural sufficiency in new buildings, the demolition or relocation of existing ones, building changes or when buildings are significantly renovated or altered. The National Fire Code of Canada (NFC) complements the NBC by providing minimum fire safety requirements for buildings, structures and areas where hazardous materials are used, thereby ensuring an adequate level of fire protection and prevention in buildings.

Human Resources Skills Development Canada (HRSDC) is accountable as regulator for Occupational Safety and Health (OSH) matters, which includes responsibility to monitor and enforce Canada Labour Code Part II, including Part XVII Safe Occupancy of the Work Place. Part XVII of the Canada Occupational Safety and Health (COSH) Regulations outlines the requirements pertaining to emergency evacuation plans, procedures, instruction and training, meetings of emergency wardens, and fire evacuation drills.

Treasury Board has developed OSH as a key policy and monitors Federal Departments' performance through its specific OSH guidelines and standards. The Treasury Board Occupation Safety and Health directive "Chapter 2-17 Use and Occupancy" states that Departments shall ensure that the requirements of the COSH Regulations Part XVII "Safe Occupancy of the Workplace" are applied in every workplace occupied by employees.

Treasury Board of Canada Standard 3-1, Standard for Fire Safety Planning and Fire Emergency Organizations, establishes the minimum requirements for fire safety plans, including the organization of designated staff for fire emergency purposes.

PWGSC established the Health, Safety, Security, Emergencies and Administration Sector in CSHRCB to be accountable for these aforementioned corporate functions. PWGSC Departmental Policy 078, Workplace Emergency Evacuation Plans (April 2000), presents the requirements for workplace emergency evacuation plans, including fire evacuations.

The requirements for departmental compliance covered in this audit are presented in Canada Labour Code - Part II, Regulations Respecting Occupational Safety and Health Made Under Part II of the Canada Labour Code (CLC Regulations), Treasury Board of Canada Standard 3-1, for Fire Safety Planning and Fire Emergency Organizations and PWGSC Departmental Policy 078, Workplace Emergency Evacuation Plans.

Place du Portage, Phase III (3,635 PWGSC employees);
King Edward Building (379 PWGSC employees);
Birks Building (142 PWGSC employees);
Plouffe Park (61 PWGSC employees); and
Conference Centre (27 PWGSC employees).

The audit objective did not include an examination of the impacts of utilizing Alternate Forms of Delivery service providers.

The following audit criteria were reviewed and accepted by CSHRCB, RPB, and TBS.

Criteria 1: Fire emergency plans and procedures for Crown-owned buildings are compliant with the following elements of DP 078.
Sub-Criteria:

Compliance with Annex A, Section 1 Emergency Evacuation Plans and Section 2 Emergency Procedures for Fire.
Compliance with Annex A, Section 3 Building Emergency Organizations (BEO), Part 3 Evacuation Drills.

Criteria 2: Fire emergency plans for Crown-owned buildings comply with Treasury Board's Standard 3-1 Section 2.3 which states "Review and acceptance which states (a) The fire safety plan is to be prepared in cooperation with the fire department. (b) The fire safety plan shall be reviewed and signed by the senior officer (*). (c) The signed fire safety plan shall be forwarded to the District Office of Labour Canada for review and acceptance prior to implementation".

*Senior Officer according to TB Standard 3-1, Section 1.5 "means the highest ranking official of any department or agency occupying space in a building or facility and being responsible for the preparation and administration of the fire safety plan. The person so identified is to be located in that building.

The audit team developed a Fire Emergency Evacuation Plan Checklist that was reviewed and accepted by CSHRCB, RPB, TBS Real Property and Materiel Policy and Safety Directorate, and TBS Health & Employee Services Directorate. At the request of TBS, the examination was enhanced to include Section 2.3 of Treasury Board's Standard 3-1, even though it is not a requirement in PWGSC's DP 078.

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2 Findings, Conclusion and Recommendations

2.1 Findings

A. Compliance with Annex A, Section 1 Emergency Evacuation Plans, and Section 2 Emergency Procedures for Fire

The audit expected to find fire emergency evacuation plans that were compliant with all of the requirements.

The audit found that fire emergency evacuation plans, including building schematics and floor diagrams, did not contain much of the required information outlined in Annex A, Sections 1.3, of DP 078. Plans were especially deficient with regard to information on the identification and management control of fire hazards in the building.

Four of the five facilities did have readily accessible fire emergency evacuation plans. One building had a three-page "fire and emergency evacuation procedures" document, rather than a complete fire emergency evacuation plan. This document, when combined with other documentation (i.e., the fire fighters copy), was partially compliant with DP 078.

Of the four buildings with fire emergency evacuation plans, one building had a fire emergency evacuation plan that was majority compliant with DP 078. Three buildings had a fire emergency evacuation plan that was partially compliant with DP 078.

The fire emergency evacuation plans had the following common deficiencies:

Identification of personnel requiring special assistance was inconsistent and insufficient to ensure their safe and quick evacuation in emergency situations;
Control of fire hazards, including hazardous materials was not consistently and sufficiently identified (i.e., type of hazard, location, quantity, and containment method(s));
Schematic diagrams of the buildings themselves were missing;
Schematic diagrams for the floors at each of the buildings were not up-to-date and did not always show the type and location of all fire protection equipment in the building. At one building, the floor schematic diagrams were not posted in the elevator lobby or adjacent to any exit stairwell; and
The content of the plans had not been regularly reviewed to ensure their accuracy, continued relevance, and completeness.

During the interviews and examination of key documents, the audit found that officers responsible for preparing building fire emergency plans were not adequately aware or understanding of the requirements and their responsibilities.

B. Compliance with Annex A, Section 3 Building Emergency Organizations (BEO), Part 3 Evacuation Drills

The audit expected to find reports submitted on building evacuation or emergency drills that were undertaken at least once a year.

The audit found that, with the exception of one building, evacuation or emergency drills were not conducted once a year as required by DP 078. Documentation of evacuation or emergency drill reports was also generally insufficient and varied greatly in their consistent quality.

More specifically, the following deficiencies on building evacuations or emergency drills and reports were found:

Concerning drills:

one building did not conduct evacuation or emergency drills - this building is a conference centre where there is a risk that those attending to the occupants might not be prepared for potential evacuation or emergencies;
three of the four buildings having had evacuation or emergency drills were not compliant with the requirements to have had at least one drill during the past 12 months;

Concerning reports:

three of the five buildings did not have documentation on the length of time required to evacuate the building;
two of the five buildings had not produced drill reports that contained the base information required;
four of the five buildings had discussed the drill at a Health & Safety Committee meeting; and
one building had no relevant documentation.

The deficiencies and the inconsistent practices found during the audit indicated a lack of corporate oversight and monitoring.

C. Compliance with Treasury Board Standard 3-1, Section 2.3 (not required by DP 078)

The audit expected to find building fire safety plans prepared in cooperation with the local fire department, and as prescribed by the Canada Labour Code, Part II.

Although not a mandatory requirement, the audit found that building fire safety plans were often not prepared in cooperation with the fire department and as prescribed by the Canada Labour Code, Part II; and they were often not being reviewed and signed by the senior officer responsible for the building. The documents were several years old in some cases, and so they may not have accurately reflected the current state of the buildings' fire emergency preparedness.

More specifically, the audit found the following deficiencies with regard to compliance with TB Standard 3-1:

Section 2.3 (a): The Fire Prevention Office of Ottawa Fire Services approved two buildings' fire safety plans - one in December 2003 and one in April 2005. The other three buildings had no evidence that the fire safety plan was prepared in cooperation with the local fire department.
Section 2.3 (b): Only one of the five fire safety plans was reviewed and signed by the responsible senior officer; it was signed in December 2003.
Concerning Section 2.3 (c), one building submitted its last fire safety plan to the Office of the Fire Commissioner of Canada within PWGSC May 27, 1985.

During the planning phase, the audit found unresolved policy discrepancies between PWGSC's DP 078, TB Standard 3-1 and the CLC Regulations . Specifically, in the assignment of responsibility for preparing and maintaining fire emergency evacuation plans, DP 078 assigns responsibility for a broader range of buildings than TB Standard 3-1. According to the Treasury Board Standard, PWGSC is responsible only for those buildings where the Department is the owner, occupant and primary tenant. TB Standard 3-1 requires PWGSC to submit fire safety plans to HRSDC Labour Services for review, while DP 078 does not make this requirement.

2.2 Conclusion