Northern Safety Network Yukon Quality Assurance Program ... · - Leadership for Safety Excellence...

Quality Assurance Program

1 Version: November 2016

Northern Safety Network Yukon


For

Health and Safety Audits



Definitions and Acronyms ATP Auditor Training Program: a program designed to instruct participants in the

requirements and methods of performing a NSNY workplace health and safety audit.

ARC Audit Review Committee

Audit A structured process used to verify the health and safety performance of a management system as compared to an industry-accepted standard

Auditor (Internal) An individual who has the qualifications and skill to measure H&S performance against a given standard and conducts the internal audit for their employer.

Auditor (External) A Consultant who has achieved Northern Safety Network Yukon endorsement. The External Auditor will have the qualifications and skill to measure H&S performance against a given standard in order to conduct external COR/SECOR certifying audits for employers.

Basic Health and Safety Program

A basic guideline used to manage employer health and safety activities

CFCSA Canadian Federation of Construction Safety Associations (CFCSA). The association administers the Certificate of Recognition program across Canada. Northern Safety Network Yukon is a member of the CFCSA.

COR The Yukon Certificate of Recognition: A health & safety partnership program with YWCHSB, Northern Safety Network Yukon and industry. The COR is a voluntary program that is widely used as a pre-qualification requirement for many purchasers of construction services. I.e.- submission on tenders. An employer who successfully meets or exceeds the program minimum requirements becomes COR registered in the territory.

COREL Certificate of Recognition Equivalency Letter. This is for out-of-territory COR companies who would like to bid on work in Yukon.

Employer An employer or organization being audited, sometimes referred to as the Auditee

Employee An individual who works for an employer or organization and is compensated for his/her services. This person may be full-time, part-time or retained on a contractual basis

Full-time Yukon site Employee

An employee is deemed to be full-time (regular or permanent) when he/she is employed in a continuous capacity for the COR company. This individual's name must appear on the company's payroll and be covered by the firm's WCB account. The employee must be working full time on the Yukon site operations (i.e.: the company's internal auditor cannot be living/working outside of the Territory, they must be dedicated to the Yukon operations and managing COR/internal audits from Yukon).

H&S Health and Safety

NSNY Northern Safety Network Yukon

OH&S The occupational health and safety unit of YWCHSB

Out-of-Territory TLC

This is a Temporary Letter of Certification for out-of-territory companies who would like to bid on work in Yukon and do not have COR in another jurisdiction, however have initiated the COR process.

SECOR The Yukon Small Employer Certificate of Recognition. A health & safety partnership program with WCHSB, Northern Safety Network and industry. The SECOR is a voluntary program that is widely used as a pre-qualification requirement for companies that employ less than 10 employees. An employer who successfully meets the program minimum requirements becomes SECOR registered in the territory.

TLC Temporary Letter of Certification. This is given to a company who has initiated the COR process, and would like to bid on work in Yukon. This allows the company to secure an active worksite in order to have their external COR certifying audit carried out.

YWCHSB Yukon Workers’ Compensation Health and Safety Board.



COR/SECOR Forms

The following up-to-date forms and information are available to download on the NSNY website:

http://www.yukonsafety.com/default.htm

Determining COR ™ Needs form

Company COR/SECOR application form

COR Equivalency (COREL) Application form and Element 14 & 15 Self-audit checklist

Internal Pre-audit Checklist

External Pre-audit Checklist

NSNY COR/SECOR Audit document (up-to-date version)

List of NSNY endorsed external auditors

External Auditor Evaluation

COR/SECOR Audit Guide

Internal Audit Tips and Tricks

NSNY External Auditor endorsement process and application form

http://www.yukonsafety.com/default.htm



1. Quality Assurance Program Policy for NSNY Audits

The Northern Safety Network Yukon (NSNY) is dedicated to providing employers with quality services

throughout the territory. Through our health and safety training programs and active partnerships,

Yukon employers can reach a high level of health and safety excellence.

The NSNY is committed to maintaining health and safety excellence in Yukon workplaces through the

development and implementation of a quality assurance program for COR audits. Its primary focuses

will be on monitoring quality and ensuring compliance with audit protocol, and corrective action follow-

up. Training and system-wide measurements will be used to assist employers with future health and

safety initiatives.

This quality assurance program is designed to ensure audits are performed in accordance with identified

standards that apply to all employers, auditors, auditors in training and NSNY staff.

Northern Safety Network Yukon takes an active role in providing direction, training and acts as liaison

between industry, external auditors and YWCHSB to support success in safety management systems.

Northern Safety Network Yukon’s intention is that this team approach to quality management will make

positive contributions in the overall reduction to injuries in Yukon workplaces.

Sheila Sergy Executive Director Northern Safety Network Yukon



1.1 Roles and Responsibilities

Northern Safety Network Yukon (NSNY)

The roles and responsibilities of the NSNY include but are not limited to:

• Managing the Quality Assurance program

• Offering training to meet the requirements

• Internal and External Auditor Training Program design and updates

• Maintain record of External Auditor endorsement, maintenance and certifications

• Liaison with both auditors and auditees, YWCHSB, ARC, CFCSA

• Conflict resolution relating to the audit program

• Liaising with employers, workers and the YWCHSB regarding related industry issues

• Reviewing audits and health and safety manuals

• Maintaining a current database on COR and SECOR status

• Control and security of audit documents.

Employers

The roles and responsibilities of employers participating in the COR/SECOR program include but are not

limited to:

• Ensuring conflicts of interest are avoided

• Ensuring audits are properly planned and scheduled

• Ensuring all areas are audited for COR and SECOR certification

• Fostering a positive audit environment by assisting and co-operating with the auditor so that

audit objectives can be met

• Providing access to facilities and supporting information as requested by the auditor

• Actively participating in the COR and SECOR programs and for COR, maintaining a full-time

company internal auditor on staff.

• Developing corrective action(s) when required.

• Using the NSNY auditee evaluation, provide comment on the audit process to assist with

continuous improvement.



2. COR/SECOR Program Requirements

2.1 Eligible Employers

Any employer with an active Yukon WCHSB account is entitled to use the NSNY Audit system.

Certificate of Recognition (COR) eligible: Companies with 9 or less employees

Small Employer Certification of Recognition (SECOR) eligible: Companies with less than 10 employees.

2.2 COR/SECOR Certification Process

Step 1: Health & Safety Program Registration

The employer must submit a COR/SECOR Health and Safety Program Application form to NSNY.

Step 2: Mandatory Training Requirements

Certificate of Recognition (COR) Program

All companies who choose to pursue COR certification with the NSNY must have a minimum of one full-

time Yukon employee attend and achieve certification in the required COR courses. The same person is

not required to take all the courses they may be divided among employees; however, the auditor must

complete the PHSM and Auditor training. Below are the required COR courses:

- Principles of Health & Safety Management (PHSM) (no expiry) (pre-requisite for Internal Auditor training)

- Leadership for Safety Excellence (LSE) (Valid for 3 years) **The majority of full-time supervisors

(i.e.: 50% or more of the company’s supervisory staff) are required to hold a valid certificate in Leadership for Safety Excellence

- Internal Auditor Training Program (Valid for 3 years) - Internal Auditor student audit - WHMIS Train-the-Trainer (Valid for 3 years) OR Basic Instructional Techniques (no expiry) - Return to Work (RTW) (Valid for 3 years) – the individual must complete Basics of Workers

Compensation & RTW Introduction and either RTW for Large Business or RTW for Small Business (Valid for 3 years)

*Re-certification options are available for training courses. Please contact the NSNY office for more

information and to check eligibility.

Small Employer COR (SECOR) Program

All companies who choose to pursue SECOR certification with the NSNY must have a minimum of one

full-time Yukon employee attend and achieve certification in the required SECOR courses. The same

person is not required to take all the courses, they may be divided among employees. Below are the

required SECOR courses:



- Principles of Health & Safety Management (PHSM) (no expiry) - Leadership for Safety Excellence (LSE) (Valid for 3 years) **The majority of full-time supervisors

are required to hold a valid certificate in Leadership for Safety Excellence (i.e.: 50% or more of the company’s supervisory personnel)

- Return to Work (RTW) (Valid for 3 years) – the individual must complete Basics of Workers Compensation & RTW Introduction and RTW for Small Business (Valid for 3 years)

*Re-certification options are available for training courses. Please contact the NSNY office for more

information and check eligibility.

Training and Course Equivalency Equivalencies may be granted for some training courses that have been completed though an affiliate of the Canadian Federation of Construction Safety Associations (CFCSA) http://www.cfcsa.ca/index.html upon review of valid course certificates or documentation. Equivalencies will be coordinated through the NSNY office and costs may apply.

Step 3: Health & Safety (H&S) Program Review

Upon registration in the COR/SECOR programs by submitting the COR/SECOR application form, the

company will then submit their health and safety manual to the NSNY for review. The NSNY will review

the H&S manual for content and provide feed-back for improvement to ensure that the company safety

program meets or exceeds standards. Once the H&S manual has been approved by the NSNY and

training requirements have been met, a 180-day Temporary Letter of Certification (TLC) will be issued.

Companies shall then implement their health & safety program and compile at least 3-6 months’ worth

of documentation for the auditor to review.

Step 4: External Certifying Audit

Employers pursing COR or SECOR certification shall initiate a certifying (also referred to as qualifying)

external audit of their Company Health and Safety Program using a NSNY endorsed External Auditor of

their choice and the NSNY Audit document.

http://www.cfcsa.ca/index.html



3. Temporary Letter of Certification (TLC)

3.1 Temporary Letter of Certification (TLC) Eligibility

To be granted a Temporary Letter of Certification (TLC), a company must submit an application to the

COR/SECOR program and submit a copy of their company health & safety manual. The NSNY will

perform a safety manual review and check that training requirements have been met. Upon approval of

the safety manual, a TLC will be issued (valid for 180 days) provided:

• The employer has completed and is certified in all COR/SECOR training courses;

• The employer submitted their Health & Safety Manual to the NSNY for review to confirm

that all elements are in place;

• An extension has not been granted within the previous 12 months.

NOTE: The safety manual review does not verify the implementation and performance of the entire

H&S management system only the content on the health and safety manual.

In order for a company to re-apply for a temporary letter of certification (TLC), a period of 12 months

must elapse between the expiration date of the old TLC and the requests for a new TLC. In some

circumstances, the NSNY will consider an adjustment to this time frame.

3.2 Temporary Letter of Certification (TLC) Extensions

Extensions will be issued at the discretion of the NSNY up to a maximum of the original time frame of

the TLC (90 or 180 days). The employer is required to submit a written request for an extension to the

NSNY that:

• explains the reason(s) for applying for the extension.

• explains an active worksite was not available for completion of the audit process within the

time-frame specified in the TLC.

NOTE: If it is shown that an active worksite was available and the audit was not undertaken, the TLC

extension may be revoked.

The NSNY may grant an extension to the Temporary Letter of Certification (TLC) to those employers that

have submitted their external audit for certification and the audit is in the review process.



4. Out of Territory COR Equivalency (COREL)

4.1 Out-of-territory COR Equivalency (COREL)

The NSNY is a member of the Canadian Federation of Safety Associations (CFCSA) and can only grant COREL to companies with COR™ from affiliates of the CFCSA. Please visit the following website to see the list of approved organizations: http://cfcsa.ca/

For employers that have attained their provincial Health & Safety COR/SECOR certification through an affiliate of the CFCSA and are applying for equivalency to the Yukon COR/SECOR program to bid in the territory the requirements are:

• Submission of the COREL application form

• Submission of a copy of their COR certificate from their home jurisdiction

• Submission of a letter of good standing from their construction safety association regarding

COR/SECOR standing in their home jurisdiction.

• Submission of the self-audit checklist performed by the company on Element 14 and

Element 15 of the Yukon COR audit document

• Submission of the administrative review fee.

Once the above has been submitted, reviewed and approved, the NSNY will issue a Certificate of

Recognition Equivalency Letter (COREL) valid for a maximum of 6 months, or until the expiration date

specified on the Letter of Good Standing from the applicant company’s home jurisdiction.

Once a worksite or YWCHSB account is established, an external audit must be completed and submitted

to NSNY prior to the expiration date of the COREL. A Yukon site employee(s) must also register for and

complete the required COR training courses. If successful, a three year COR/SECOR will be issued.

Note: Unsuccessful bidders may receive ONE extension to their COREL, upon written request, for

bidding again in Yukon when the original COREL has expired (see below). For those employers that

achieve the Certificate of Recognition or Small Employer Certificate of Recognition, they are required to

maintain their COR/SECOR according to NSNY requirements.

4.2 Out-of-territory COR Equivalency (COREL) Extensions

If an employer has not had any work in Yukon during the time of their original COREL they may be

eligible for an extension. To apply for an extension, an employer must submit:

• An up-to-date copy of their Letter of Good Standing from their home jurisdiction



• A letter confirming that they have had no work in Yukon during the time of their original

COREL.

• NSNY may request that these letters be notarized.

For the COREL companies applying for an extension to a COREL, only ONE extension will be granted on

the condition that the company did not have an active worksite in Yukon to audit during the time the

COREL was active. Extensions may be granted for a maximum of 180 days. Once the COREL extension

has expired, the company must re-apply to the program to receive another COREL.

4.3 Temporary letter of Certification (TLC) – Out-of-Territory

For companies who do not currently have COR/SECOR in their home jurisdiction and would like to bid on

tenders in Yukon that require COR certification, they may be eligible for an Out-of-Territory Temporary

Letter of Certification (TLC).

The requirements for out-of-territory employers applying for a Temporary letter of Certification (TLC)

are:

• Submission of their Health & Safety program (Safety Manual) along with review fees for an

administrative audit review by NSNY personnel to ensure it meets industry standard.

• Registered in, or completion of the required COR courses by a full-time employee, or

• Application for and granted equivalency for one or more of the required courses.

4.4 Temporary Letter of Certification (TLC) Extensions – Out-of-Territory

For the out-of-territory employers applying for an extension to a TLC, only ONE extension will be

granted on the condition that one Full-time employee register and actively participate in the required

COR courses and the company did not have an active worksite in Yukon to audit during the time the TLC

was active.



5. Process for External Audits

5.1 Pre-Requisites for COR External Audits

Before the external audit may proceed the employer shall have:

a. Completed and submitted the COR application.

b. Have at least one full-time employee complete; Principles of Health & Safety Management,

Leadership for Safety Excellence, Internal Auditor Training Program (*certification), Return to

Work Training, and one of the following Train-the-Trainer programs – WHMIS OR Basic

Instructional Techniques.

*The Internal Auditor Certification requires submission and approval of a “student/internal

audit”

c. Have the majority of full-time supervisors complete the Leadership for Safety Excellence course

(i.e.: 50% or more of the company’s supervisory personal.)

d. Have submitted to the NSNY and received approval of their company Health & Safety Manual.

e. An implemented/established H&S program (company shall have at least 3-6 months of

documentation available for the auditor to review).

f. Have a medium to peak season active work site available for the audit. Having a medium to peak

season active work site means that the company being audited is able to present to their

external auditor, a good representation of the daily operations and work activities that are

carried out during their busiest and most active time of the year. Staffing numbers shall be

above 50% of their usual compliment during the company’s busiest season/period for the year.

It is the sole responsibility of the employer to schedule the audit during active, medium t peak

work periods.

g. Submitted an external pre-audit checklist and received approval from the NSNY to proceed with

the external audit.



5.2 Pre-Requisites for SECOR External Audits Before the external audit may proceed the employer shall have:

a. Completed and submitted the SECOR application.

b. Have at least one full-time employee complete: Principles of Health and Safety Management

and Leadership for Safety Excellence and Return to Work Training

c. Have the majority of full-time supervisors complete the Leadership for Safety Excellence course

(i.e.: 50% or more of the company’s supervisory personnel)

d. Have submitted to the NSNY and received approval of their company Health & Safety Manual.

e. Implement and establish the H&S program (company shall have at least 3-6 months of

documentation available for the auditor to review).

f. Have an active work site available for the audit that is during medium to peak season for the

company. Having a medium to peak season active work site means that the company being

audited is able to present to their external auditor, a good representation of the daily

operations and work activities that are carried out during their busiest and most active time of

the year. Staffing numbers shall be above 50% of their usual compliment during the company’s

busiest season/period for the year. It is the sole responsibility of the employer to schedule the

audit during active, medium t peak work periods.

g. Submitted an external pre-audit checklist and received approval from the NSNY to proceed with

the external audit.

5.3 Conducting the Audit

5.3.1 External Audits

Having met the pre-requisites for the external audit (outlined above), the employer (auditee) will review

the current list of NSNY endorsed external auditors by visiting the NSNY website at

www.yukonsafety.com. The employer then contacts the individual auditors to employ their services. The

NSNY recommends the employer contact several auditors for quotes and availability before choosing.

Once a NSNY endorsed external auditor is chosen, a Pre-Audit Checklist must be completed and

submitted to the NSNY for review and approval

http://www.yukonsafety.com/



5.3.2 NSNY Endorsed External Auditors

A list of NSNY endorsed external auditors is available to employers on the NSNY website. Employers

must select an auditor from this list.

Employers will avoid Conflicts of interest which include, but are not limited to, the following:

• auditor was directly involved in setting up the company’s health and safety program,

• auditor was a past employee of the company within the last year,

• auditor’s company is a sub-contractor to the company,

• auditor performed the previous external certification audit

5.3.3 External Audit Costs

Employers are responsible for contracting the external auditor.

Costs can vary depending on company size, location and scope of operations. Prior to commencing the

audit process NSNY recommends that the employer request,

1. A quote from several endorsed auditors to complete the audit and;

2. References and/or experience letter outlining relevant experience and training

5.4 Internal Audits

Company internal audits must be carried out by a full-time Yukon site employee of the company who

has achieved internal auditor certification through the NSNY. The employer can submit a request to

NSNY to contract a NSNY trained auditor to assist with carrying-out the audit, however the employer

must still ensure that they have a person on staff with a valid internal auditor certificate to meet the

requirements of COR.

Prior to conducting the audit, a Pre-Audit Checklist for Internal Audits must be submitted to the NSNY to

confirm that the internal auditor has their certification up-to-date, all other requirements are met, and

that all required COR training certifications are valid. Once the checklist has been approved, the NSNY

will inform the company that the audit may proceed.

The employer must have a medium to peak season active work site(s) for this internal audit to proceed.

It is the sole responsibility of the employer to schedule the audit during active, medium to peak work

periods.



6. Audit Guidelines

Both External and Internal Auditors shall follow the instructions and guidelines for carrying out the

audit. Instructions and guidelines are found in the NSNY Standard Audit Document. For further

information, please review the Internal Auditor Training manual.

6.1 Audit Document Selection

There is one NSNY Audit document that is used to audit both COR and SECOR companies. The audit

document is designed for the construction industry and Yukon Businesses. The audit document can be

downloaded free of charge from the NSNY website.

Employers must use the official and current version of the NSNY audit document in order to achieve a

Certificate of Recognition (COR) or Small Employer Certificate of Recognition (SECOR) through the NSNY.

The most current version will always be available on the NSNY website. Instructions on how to

download are also provided on the website.



7. Audit Submission and Review

The employer is responsible for completing the audit within 45 calendar days (pre-audit meeting to

close-out meeting). The employer is responsible for submitting completed audits via email to the NSNY

within 45 days from the end of audit (audit close-out meeting) or before the company’s anniversary date

(whichever comes first).

7.1 NSNY Audit Review

A quality assurance review is performed by NSNY personnel on all internal and external audit

documents. The reviewer will contact the auditor should any adjustments be required.

7.2 Minimum Score for COR and SECOR Audits

To meet the COR/SECOR standards the external/internal audit must:

1. Attain an 80% overall score; and

2. Attain a minimum of 50% in each element; and

3. Meet and/or exceed the established quality assurance standards of both NSNY and YWCHSB

7.3 Quality Audit Protocol

Quality audit protocol requires that the completed audit document shall

• Have all required fields completed in full;

• Provide justification for any questions that were marked N/A.

• Provide relevant feed-back with the goal of continuous improvement in the auditor executive

summary report that parallels scoring.

• Have comments for ALL questions in the audit document regardless of scoring. Ensure

comments provide insight into all used verification techniques and points awarded. One-word

comments do not convey adequate information; full sentences shall be used to ensure clarity.

• Have an executive summary that includes comments on the strengths and at least one

recommendation for each negatively scored question in the audit document. Best practice is to

offer recommendations to the company in all areas where deficiencies were noted.

7.4 External Audit Review for COR/SECOR

When the external audit meets and/or exceeds the COR/SECOR standard the NSNY will advise YWCHSB.

A YWCHSB designate will review the audit and perform an OH&S file review of the employer.



7.4.1 COR/SECOR Accreditation

COR/SECOR will be issued when all requirements have been met. The certificate is jointly signed by the

NSNY, Executive Director and the YWCHSB, Director of OH&S.



8. COR Maintenance

Once certification is achieved, COR is maintained by keeping all training certifications valid and through

the combined external and internal progress audits. The following maintenance schedules are in place:

• Internal progress audit in the 2nd year;

• Internal progress audit in the 3rd year; and

• External progress audit in the 4th year.

The audits must be completed and submitted to NSNY prior to the anniversary date of initial

certification. Extension requests shall be made in writing to the NSNY Executive Director and provide a

rational for the extension, and be submitted to the NSNY for approval prior to the anniversary date.

NSNY will respond with formal approval. The original anniversary date will still apply on future audits.

When an employer has allowed their COR to expire, it is the responsibility of the employer to re-apply

into the program.



9. SECOR Maintenance

Once certification is achieved, SECOR is maintained by keeping all training certifications valid and

through the completion of external audits every third year.

Due to the three-year period between external audits, the NSNY recommends that in order for

employers to stay up-to-date and current with their health and safety program, they may choose to

undergo a yearly review of Field Level Documentation. The NSNY will carry-out the Field Level

Documentation review upon request from the employer.

The Field Level Documentation Review will consist of:

Complete hazard assessment forms

New employee training records and refresher training records (including copies of certificates)

Inspection reports

Incident reports (including near-miss reports)

The audits must be completed and submitted to NSNY prior to the anniversary date of initial

certification. Extension requests shall be made in writing to the NSNY Executive Director and provide a

rational for the extension, and be submitted to the NSNY for approval prior to the anniversary date.

NSNY will respond with formal approval. The original anniversary date will still apply on future audits.

When an employer has allowed their SECOR to expire, it is the responsibility of the employer to re-apply

into the program.



10. Changes to Existing COR/SECOR

10.1 COR/SECOR Certificate Anniversary Dates

Both internal and external audits are due prior to the anniversary date on the COR/SECOR Certificate.

This date represents the last day of the company’s original certifying audit. The Anniversary date will

remain on the original date with every re-certification audit.

An employer can request that their anniversary date be changed to accommodate medium to peak

levels of work activities. This request shall be made in writing, state the reason for the change and be

submitted to the Executive Director for approval. If approved, the anniversary date will be adjusted on

the certificate following the next re-certification audit.

10.2 Registration of a new division of a COR/SECOR company

If an employer expands its scope of operations, they may request COR/SECOR registration for the new

division through NSNY. The NSNY will advise the employer of the necessary documentation required

and forward the request (along with documentation) to YWCHSB for confirmation. When there is a

significant change in the scope of work, YWCHSB may require new certification. The following

documentation is required prior to the issuance of any changes to the COR/SECOR:

• Copy of the employer’s registration with the Corporate Registry that indicates the ownership

remains the same as the COR/SECOR holder(s).

• A letter from the employer that shows:

o The establishment of a YWCHSB account indicating the number and industry code.

o A description of the type of work being done by the new division or company.

o Verification that the Health & Safety Program used is the same as when the original

COR/SECOR was issued.

10.3 Changes in ownership

The following criteria will be used to determine if a change in ownership or management will affect a

company’s COR/SECOR.

• 51% or more continued ownership. The ownership of a business generally determines the

approach to occupational health and safety. If the ownership continues at 51% or more the

COR/SECOR will be continued.



• Where there is not a 51% or more continued ownership, COR/SECOR status will be reviewed and

new certification may be required. Exemptions to this rule may be granted if the business

operations remain substantially the same and the following situations arise:

o The business ownership is relatively removed from the day to day operations of the

company and does not supervise staff and/or make management decisions (as is the

case with large publicly-traded organizations).

o The change is among existing owner(s). This includes changes in partnership

composition, a sole proprietor or partnership incorporating, a corporation changing to a

partnership or sole proprietor, or changes between a partnership and a sole

proprietorship. At least one related person remains after the change and business

operations remain substantially the same.

o The new ownership is a family member of the prior owner. Factors to be considered

include whether the undertaking remains the same, the new ownership has been

historically involved and whether the previous ownership is still active in the business.

In all cases where there is a change in ownership and/or senior management, the new senior person

must review the company safety policy and either sign and adopt it as is or make the necessary changes

to reflect current company health and safety management beliefs.

10.4 Joint Ventures

If a company with 51% or more shares in the joint venture is owned by the COR certified company, then

the venture is COR certified. Where the COR certified company does not own 51% or more, an external

audit must follow regular NSNY procedures for COR certification.

10.5 Recertification of a COR company outside of Yukon

An employer holding a valid Yukon COR certificate and no longer working in Yukon can choose to opt-

out of the program or maintain their Yukon COR. If they choose to maintain their Yukon COR, external

re-certifying audits shall be conducted on current company worksites using the NSNY Audit Document

and a NSNY endorsed external auditor. Internal audits must be conducted on schedule by an employee

that holds a current NSNY Internal Auditor Training Program certificate or equivalent. All external audits

must be submitted to NSNY for a quality assurance review and endorsement by YWCHSB.



10.6 COR/SECOR Company Name Change An employer who legally changes their name and is requesting a new COR/SECOR certificate can do so by submitting a formal letter that includes:

The original name on the COR certificate and the new legal company name to be printed on the

certificate;

The company’s YWCHSB account number and industry code;

The signature of the company CEO/President

Confirmation that the company’s health & safety program and management remain the same.

A notarized stamp

A copy of your corporate registry for the new company attached



11. Below Standard COR/SECOR Audits

11.1 Company Action Plan

Following both internal and external audits that failed to achieve the minimum score, an action plan

must be submitted to outline how the deficiencies of the health and safety program will be corrected.

The action plan must include any recommendations that were identified by the auditor.

The action plan must be signed by senior management and address:

• Identified H&S program weaknesses

• Prioritization of concerns identified

• Proposed corrective actions including a description of short term and long term strategic plans

• Targeted implementation schedules and sign-off process

The action plan must be submitted to NSNY for review and approval when the minimum standard has

not been attained.

Failure to submit an action plan within the 30 days may result in initiation of the “Review of COR/SECOR

Holder’s Health & Safety Program – Appendix C”.

11.2 External Audit

Employers will contact the NSNY when the audit does not meet minimum standards. Audits that do not

meet the standard but achieve 70% or higher overall score and/or below 50% in two or less elements

may qualify for a limited scope audit.

Employers whose external audit fails to meet the minimum audit score and does not qualify for the

limited scope audit will undergo a “Review of COR/SECOR Holder’s Health & Safety Program – Appendix

C” and must have their entire health and safety program re-audited.

11.3 Limited Scope Audit

A Limited Scope Audit is defined as an audit that is conducted only on deficient areas of an employer’s

health and safety management system. Limited Scope Audits have two objectives:

1. To produce focused and measurable improvements in an employer’s health and safety

management system within a given time-frame.

2. To offer an employer with minor health and safety program deficiencies the opportunity to

achieve certification without repeating the entire audit process.

When an employer qualifies for a limited scope audit the NSNY will send a letter requesting an action

plan to correct the deficient areas of the safety program. This action plan must be received by the NSNY

within 45 calendar days from the last day of the audit (audit close-out meeting). If the NSNY and



YWCHSB accept the action plan, a limited scope audit will be set-up to re-evaluate the deficient areas.

Where practicable, the same auditor will conduct the audit.

• The limited scope audit must take place within 90 days from the last day of audit (audit

close-out meeting). Failure to meet any of these requirements may result in a full re-audit

being required and may require the initiation of the “Review of COR/SECOR Holder’s Health

& Safety Program – Appendix C” or denial of COR/SECOR. When the COR/SECOR is issued

(after successful completion of the audit on the deficient areas), the date that will appear on

the Certificate of Recognition will be the date of the original external audit.

• Employers that fail to meet the minimum requirements for re-certification within the

specified timeframe (90 days) cannot apply for a Temporary Letter of Certification (TLC) for

a period of 12 months from the certificate expiry date. NSNY reserves the right to adjust

these time-frames in special circumstances.

• Failure to submit an action plan within the 45 days may result in initiation of the “Review of

COR/SECOR Holder’s Health & Safety Program – Appendix C”.

Any extensions must be approved in advance by the NSNY.

11.4 Failure to Submit External Audits

Employers that fail to meet the minimum requirements for re-certification within the timeframe (90-

days) and lose their COR/SECOR as a result, cannot reapply for COR/SECOR or apply for a Temporary

Letter of Certification (TLC) for a period of 12 months from the COR/SECOR expiry date. NSNY reserves

the right to adjust these time-frames in special circumstances

Failure to submit an external audit by the anniversary date may result in beginning the “Review of

COR/SECOR Holder’s Health & Safety Program – Appendix C” and may result in an employer’s

COR/SECOR being revoked.


11.5 Failure to Request Re-verification Audit

Failure to request a re-verification of below standard elements may result in the initiation of the

“Review of COR/SECOR Holder’s Health & Safety Program – Appendix C” or denial of COR/SECOR.

11.6 Internal Audit

Internal audits submitted to NSNY for approval must meet established protocol and minimum score.

The employer must submit a written action plan within 30 days when audit standards are not achieved.

Upon receipt of the action plan a meeting will be arranged between the Executive Director and/or COR

Coordinator (or designate) of the NSNY and the employer to review the action plan and ensure

expectations and outcomes are clearly understood. NSNY may request that a limited scope audit be

completed by the company to correct the deficient areas of the audit.



11.6.1 Failure to Submit Internal Audit

Failure to submit an internal audit by the anniversary date may result in the initiation of the “Review of

COR Holder’s Health & Safety Program – Appendix C” and may result in your COR being suspended or

revoked. Failure to submit two consecutive internal audits will result in COR status being placed in

suspension and an external audit must be initiated within 90 days to reactivate COR certification.

Failure to do so will result in COR Certification being revoked, and the company having to resubmit to

the entire COR process.




12. Document and Data Control Objective is to establish guidelines for the control and processing of audit documents.

12.1 Audit Review

All audits submitted to NSNY will have a quality assurance review completed by NSNY personnel. The

NSNY will not change an audit score without contacting the auditor for discussion and agreement on the

proposed changes. Disagreements on changes may be forwarded to the Audit Review Committee.

12.2 Release of Information

All audit reviews and performance ratings are strictly confidential in compliance with the privacy act.

These findings will not to be released to members or anyone outside of the NSNY, except YWCHSB. Any

inquiries regarding employer COR/SECOR accreditation shall be directed to NSNY.

12.3 Retention of Records

The completed student audit document used for auditor certification will be reviewed, the score

recorded and the document kept on file electronically. Records will be kept on file for a minimum of

three years.

All external and internal audits will be entered into the secure NSNY administration system (CALVIN). All

COR/SECOR certificates, Letter of Good Standing (LoGS), Audit Quality Assurance documentation, and

completed electronic audit documents will be kept in secure company files at the NSNY offices.

12.4 Audit Reviewers

The audit reviewers will be NSNY personnel and the same “code of ethics” shall apply to them as for

NSNY endorsed auditors. All information contained in the audit document is strictly confidential and it

shall not be discussed, copied or passed on to anyone outside of the NSNY except upon request by

YWCHSB or the auditee.

12.5 Database Information

NSNY will maintain the following records on their computer database:

Employer Information: • Name of employer as well as subsidiary name • Address

• Contact Name

• Telephone/Fax number/email address

Certificate of Recognition information:

• YWCHSB Account and Industry Code number issued to COR/SECOR.

• Audit Date

• COR/SECOR number and expiry date

• Auditor name

• Audit history



13. Auditor Certification Standards

13.1 Internal Auditor Standards

Minimum standards for auditor training require trainees to:

• Have a working knowledge of health and safety program development, implementation and

management;

• Successfully complete the NSNY’s Principles of Health and Safety Management or equivalent

(prior to completing the NSNY Internal Auditor Training Program);

• Attend two days of training in the Internal Auditor Training Program;

• Attain a minimum of 80% average in classroom training (theory, practices, quiz);

• Submit a satisfactory student audit within 6 months of completing the course. All audits are

reviewed and must meet or exceed minimum standards before an Internal Auditor Certificate is

issued by the NSNY;

• Ensure that audits are completed from start date to the last day onsite within a 45-day time

period. Audits shall also be submitted to the NSNY within 45 days from the audit close-out

meeting or before the company’s anniversary date.;

• The individual may be required to repeat the entire Internal Auditor Training Program when an

unacceptable student audit is submitted within the 6-month timeframe; and

• Complete and submit any required corrections promptly.

Only the audits that are completed and submitted within the six-month timeframe will be reviewed,

unless a pre-arranged extension has been granted by the NSNY.

*Equivalencies may be granted for equivalent training though the Canadian Federation of Construction

Safety Associations (CFCSA) upon review of valid course certificates. For more information on CFCSA

organizations, visit their website: http://www.cfcsa.ca/

13.2 Maintaining Internal Auditor Certification

To maintain current certification internal auditors will:

• Submit one internal or external audit annually for review by NSNY personnel; verification will be

maintained on the NSNY database;

• Ensure Internal Auditor certification is re-certified every 3 years, prior to expiration date of the

current certification. All extensions to this timeframe will be reviewed on an individual basis;

and

• Abide by the NSNY auditor Code of Ethics at all times.



An industry accepted practice for companies with more than one certified internal auditor would be to

submit one audit listing all internal auditors involved in the audit process for auditor or COR

maintenance. Auditors must maintain their own certification.

13.3 Code of Ethics for NSNY Internal Auditors

Auditors must strive to maintain a high level of professional conduct at all times. To ensure that quality

audits are consistently performed auditors must:

• Maintain sound judgment in pursuance of their duties.

• Maintain the highest standards of honesty and integrity.

• Ensure that information is accurately interpreted and communicated.

• Ensure that information is safeguarded and kept confidential at all times.

• Ensure that information is based on objective findings and free of bias.

• Maintain quality standards through professional development.

Auditor candidates are required to sign the Code of Ethics when attending NSNY Auditor Training

Programs

13.4 Endorsed External Auditor Standards

Endorsed external auditors are independent consultants who have completed the requirements to

become endorsed external auditors through NSNY

External Auditors are required to:

• Only use the NSNY audit instrument to measure employers for COR maintenance;

• Abide by the NSNY auditor Code of Ethics at all times;

• Sign NSNY Endorsed External Auditor Agreement; and

• Maintain their External Auditor Endorsement

Employers must choose an external auditor from the NSNY external auditors list to complete their

company external audit. The NSNY COR audit document must be used for all COR/SECOR external

audits.

13.5 External Auditor Endorsement Process

Please contact the NSNY for more information on the External Auditor Endorsement Process or visit the

website www.yukonsafety.com



14. Auditor Non-Conformance

14.1 Incomplete Audit Submission

When perceived audit deficiencies arise these concerns will be directed to the NSNY Executive Director

for review and investigation. The NSNY will contact the auditor when an incomplete audit has been

submitted. The NSNY will not change an audit score or comments without contacting the auditor for

discussion and agreement on proposed changes. Any required corrections must take place within a 2

business day timeframe from the date requested. Any extensions to this period may be approved by the

NSNY. Significant deviations identified may result in audit rejection and/or auditor interview which may

result in retraining and/or suspension.

Any costs associated with correcting the deficiency is the responsibility of the company being audited.

The Audit Review Committee (ARC) may become involved if an agreement to make the changes is not

achieved. The role of the NSNY is to provide guidance regarding audit protocol. For more information

on ARC, please refer to section 17.

14.2 Audit Rejection

Listed below are reasons why internal/external audits fail to meet quality standards:

Auditor failed to perform required number of interviews;

Audit was not completed within the 45-day timeframe;

Audit was not submitted to the NSNY within 45 days of the last day of on-site activities (audit

close-out meeting);

Auditor failed to perform cross section of interviews;

An inadequate number of work sites were visited;

Unacceptable use of Non-applicable (please review that section);

Information in the audit is incomplete;

Audit was not performed during the company’s medium to peak season;

Audit score does not parallel comments and executive summary;

Auditor failed to give a sense of the company’s health & safety management system; and

Audit process not followed (e.g. pre-audit checklist not submitted and approved prior to audit).

Any of the points above may result in the audit being rejected by the NSNY. The NSNY will inform the

company and the auditor in writing of the situation and will work together to achieve a satisfactory



solution with the auditor and the company. Any costs associated with correcting the deficiencies will be

the responsibility of the company or the external auditor.

14.3 Perceived Conflicts of Interest- External Auditors

When perceived conflicts of interest arise these concerns will be directed to the NSNY Executive Director

for review and investigation. The Audit Review Committee may become involved.

14.3.1 Conflicts of Interest

External auditors will avoid conflicts of interest at all times. These conflicts include, but are not limited

to, the following issues:

• An external auditor who has had direct input into the auditee’s Health & Safety program

development within the 12 months prior to the audit.

• An external auditor who stands to gain financially through recommendations made prior to

audit close-out and report submission.

• An external auditor who, through a business relationship, may be perceived to be in conflict.

NOTE: In order to avoid any perceived conflict of interest, the same external auditor will not be used by

the same company for consecutive external audits.

Conflicts of interest will be reviewed by the NSNY COR Coordinator and/or Executive Director and

discussed with the auditee and the auditor. When warranted, the auditor and employer representative

may be required to attend an Audit Review Committee (ARC) meeting to review the findings. When a

significant conflict of interest is verified, the NSNY may initiate a re-verification audit. COR/SECOR may

be revoked until the re- verification audit is complete.

14.4 Breach of Auditor Code of Ethics/Conflicts of Interest

When the NSNY determines that an auditor has intentionally breached the auditor Code of Ethics,

auditor de-certification will occur. This may also result in audit rejection and re-audit of the entire

Health & Safety program by an independent auditor, costs to be borne by the employer.

14.5 Auditor Appeal Process

An appeal may be launched by the de-certified auditor, in writing. The appeal is directed to the NSNY

for submission to Chairperson of the Audit Review Committee (ARC).



15. Employer Non-Conformance Objective is to establish uniform audit guidelines for employers.

15.1 Failure to Use Correct Audit Document

When an employer uses an incorrect audit document, the NSNY reserves the right to review the findings

and recommend corrective action(s) or reject the audit. If the NSNY is unable to resolve this issue the

findings will be reviewed by the Audit Review Committee (ARC) An employer must use the NSNY

Standard Audit Document which can be downloaded free of charge from the NSNY website

(www.yukonsafety.com). Audits completed with any other document will not be accepted.

15.2 Regulatory Non-Compliance

When an employer has been found in violation of the Occupational Health & Safety Act, the Director of

OH&S may initiate the “Review of COR/SECOR Holder’s Health & Safety Program – Appendix “C”. This

could result in:

• Granting an extension to a Temporary Letter of Certification (TLC);

• A re-verification audit; or

• Revoking of an existing COR/SECOR.

15.3 Fatalities, Serious Incidents and Injuries

When an employer has experienced a fatality or fatalities, serious incident and/or injuries, Yukon

Workers’ Compensation Health and Safety Board’s “Review of COR Holder’s Health & Safety Program –

Appendix “C”, process will begin.

It is the responsibility of the YWCHSB to initiate the process.

http://www.yukonsafety.com/



16. System Complaints

16.1 Complaints

Complaints regarding the audit process or employer COR/SECOR are to be directed to the NSNY in

writing. Complaints will be addressed by the NSNY Executive Director with stakeholders and this may

include representatives from YWCHSB and the Audit Review Committee (ARC).



17. NSNY Audit Review Committee (ARC)

The objective of ARC is to provide a forum that:

• Offers arm’s length recommendations to the NSNY Executive Director and/or Board for dispute

resolution or appeals relating to the Yukon COR Program;

• Gives recommendations to the Executive Director and/or NSNY Board on any disciplinary action

required; and

• Reviews and offers feedback on the audit standards and program development to the NSNY

Board.

17.1 ARC Roles and Responsibilities

The Audit Review Committee is comprised of representatives from industry, NSNY, YWCHSB and a NSNY

endorsed External Auditor. Their responsibilities include reviewing and making recommendation to the

Executive Director and/or NSNY Board regarding:

• Disputes relating to an audit or employer COR/SECOR process that cannot be settled between

NSNY and the employer;

• Breeches of code of ethics and auditor agreement;

• Appeals and corrective disciplinary action for auditors and/or auditees;

• Sounding board for extenuating circumstances around issuing Temporary Letter of Certification

(TLC) or COR de-certification, suspensions and/or extensions;

• Industry audit standards and documents;

• Auditor training program;

• Auditor endorsement process; and

• Annual review of ARC roles and responsibilities.

The ARC will also be required to carry out an audit spot review once (1) per year, which will be led by the

COR Coordinator to review process and ensure standards are being met.

17.2 ARC Member Selection

Members of the ARC are based on either their position within an organization (NSNY/YWCSHSB rep.),

appointment from the ARC members (External Auditor representative) or as a volunteer (industry

representative).

ARC will be made up of the following representatives:



• NSNY Board Representative

• YWCHSB Representative

• Volunteer from COR/SECOR Certified Company

• NSNY COR Coordinator and/or Executive Director as deemed fit (TBD by the ARC)

• NSNY External Auditor

Volunteer from government/municipal Representative

There are a minimum of five (5) and a maximum of six (6) positions on the ARC committee.

17.3 Application of Dispute Guidelines

An Application of Dispute can be made by an External Auditor, an employer, YWCHSB or NSNY to the

ARC. If a dispute or complaint has been requested to be heard by the ARC, the following information

must be submitted by both parties involved in the dispute to the NSNY Executive Director:

• A written statement clearly and concisely stating your position;

• A clear and concise statement must be included regarding what resolution you hope to achieve

through the dispute process; and

• All information necessary to back-up and support your position.

Complaints/disputes must be provided in writing and cannot be submitted anonymously. Once the

required documentation is received NSNY will schedule a special meeting of the ARC committee.

Recommendations from the meeting will be submitted by the Chair/Co-Chair of the ARC to the NSNY

Executive Director, who, dependent on the dispute may present it to the Board of Directors. The NSNY

Board of Directors may then respond to the recommendations; and/or schedule a special board meeting

to discuss and come to a decision on the issue.



18. Appendix C: YWCHSB- Review of COR Holders Health &Safety Program

Introduction

Yukon Workers’ Compensation Health and Safety Board (YWCHSB) believe that employers with effective

workplace health and safety management systems will have reduced work-related incidents. A

Certificate of Recognition (COR) is granted to an employer having implemented a workplace health and

safety management system that is shown to meet established standards through an external audit.

To ensure the process of granting and revoking a Certificate of Recognition is:

a) Fair; and

b) Properly reflects the employer's management of compliance with the legislated standards;

c) Procedures have been established between YWCHSB and the certifying partner.

When serious, repeat or numerous contraventions of the Occupational Health and Safety Act and

regulations occur, the effectiveness of employers’ workplace health and safety management systems

become questionable, possibly leading to review by YWCHSB. Certificate of Recognition holders

experiencing repeated contraventions, fatalities or serious incidents and injuries will warrant review.

Reviews can be requested by YWCHSB staff, the Certifying Partner, COR holders and other employers,

employees or stakeholders.

Procedure

A review of an employer’s workplace health and safety management system will be initiated if YWCHSB

identifies areas of concern when:

- Completing background checks on an employer requesting a COR.

- Undertaking inspections on employers who hold a COR.

- A complaint that includes proper substantiation is received by YWCHSB or the Certifying

Partner.

When concerns are identified which require follow-up by YWCHSB, they should be directed to the

Director of Occupational Health and Safety. The Director of OH&S is responsible for ensuring that

Employer Review Requests are legitimate.

Employer Reviews are initiated:

1. When a Certificate of Recognition request is received by YWCHSB:

a. An activity check covering a one-year period will be carried out.



b. If there has been a significant level of Safety Officer Activity with the employer, the

Safety Officer(s) will be contacted regarding the nature of the activity.

c. If the Officer indicates that there are no significant concerns with the employer in

question, the COR request will be processed.

d. If the Safety Officer and/or the person reviewing the application have concerns, the

Safety Officer will make a follow-up visit to the site prior to a Certificate of Recognition

being issued.

e. If, on the follow-up visit the Safety Officer identifies serious, repeat or numerous safety

violations, he/she will advise the person reviewing the application who will review the

Inspection Report (I.R.).

f. The Inspection Report (I.R.) (with demonstrated safety violations), will be reviewed by

the Director OH&S and the “Employer Review Procedure” may be followed.

2. When a report is received from a Safety Officer which indicates an employer with a Certificate of

Recognition had incidents or violations that are in the Officer’s opinion of a serious and/or

repetitive nature:

a. An “Employer Review Request” prepared by the Safety Officer, which includes the I.R.

and other supporting information, will be reviewed by the Director of OH&S with the

Officer involved. If the report provides appropriate substantiation, the “Employer

Review Procedure” will be followed.

3. When a complaint is received from a member of the public regarding a COR holder with possible

safety violations:

a. OH&S will review information on the COR holder and conduct an inspection.

b. If the Officer’s Inspection Report indicates that there are no serious, repeat or

numerous violations (as per sect. 1.e), further action will not be taken.

c. If the Officer’s Inspection Report indicates that there are violations that need to be

corrected and there have been no previous visits or orders written, he/she will inform

the Director of OH&S and schedule a follow-up visit.

d. If the Officer’s follow-up visit indicates that the violations have not been corrected or

new problems exist, he/she will forward a copy of the I.R. for the employer to the

Director of OH&S. The I.R. and other appropriate information will be included in an

Employer Review Request and the “Employer Review Procedure” will be followed.

4. Routine inspections by Safety Officers:



a. An inspection will be carried out by an Officer.

b. If the Officer’s I.R. indicates the employer has incidents or safety violations, that in the

Officer’s opinion bring into question the effectiveness of their health and safety

management system, he/she will notify the Director of OH&S. An Employer Review

Request will be prepared by the Safety Officer and reviewed by the Director of OH&S

and the Officer involved. If the report provides appropriate substantiation, the

“Employer Review Procedure” will be followed.

c. If the Officer’s I.R. does not indicate any serious concerns, a routine follow-up visit will

be conducted.

d. If the Officer’s follow-up visit indicates that the violations have not been corrected or

new problems exist, he/she will forward a copy of the I.R. for the employer to the

Director of OH&S. The I.R. and other appropriate information will be included in an

Employer Review Request and the “Employer Review Procedure” will be followed.

5. When a COR holder has a fatality:

a. The Director of OH&S will send a letter to the employer indicating that the employer’s

COR is under review pending the results of Occupational Health and Safety’s

investigation of the incident.

b. The letter will also indicate that the next audit conducted by the employer must be

external.

c. When the investigation has determined whether the employer will be recommended for

prosecution, the Director of OH&S, or his designate, will inform the employer.

d. If prosecution does not proceed against the employer, the Director of OH&S will meet

with the Officer responsible, and the “Employer Review Procedure” will be followed

immediately.

e. If prosecution proceeds against the employer, no further action will be taken until these

proceedings have reached a conclusion.

f. Once the proceedings have been concluded, regardless of outcome, the Director of

OH&S will meet with the Officer responsible and the “Employer Review Procedure” will

be followed.

6. Employer Review Procedure

a. If the Director of OH&S determines that an “Employer Review Request” validates

concerns with the employers’ workplace health and safety management system, a

meeting will be held with the Certifying Partner to gather additional information



regarding the employer that may need to be considered. If the concerns identified in the

Employer Review Request remain valid, a meeting with the employer, Yukon Workers’

Compensation Health and Safety Board (where appropriate the Safety Officer will be

present) and the Certifying Partner, may be requested. If concerns are not eliminated

through this meeting process, YWCHSB, and the Certifying Partner will agree on action

that the employer must take to maintain the validity of their COR. This action may

include specific training plans for employees, external audits in the place of planned

maintenance audits and limited scope audits etc., in exceptional circumstances,

YWCHSB and the Certifying Partner may agree to suspend or revoke an employer’s COR.

(See flow chart 1)

b. If, at any point in this process, the employer does not meet timelines or refuses to take

necessary action, YWCHSB will deny the COR request or revoke an existing COR.

c. The Director of OH&S will keep the appropriate officer(s), informed as to the outcome

of the employer review.

- When officers are making planned site visits they will first determine whether the employer

holds a valid COR. If the employer holds a valid COR and safety violations are noted at the site,

the employer will be informed of the Employer Review Policy and the possible consequences to

the status of their COR if the violations are not corrected or future violations are noted. This is

intended as an informational service to the employer, not a threat.

- The actions outlined in this procedure are minimums and additional procedures or

consequences may be introduced if agreed to by the Certifying Partner and YWCHSB.

- In situations where an employer has had their COR revoked or COR request denied, they will be

required to wait a period of one year before applying for recertification.

Kurt Dieckmann, CRSP

Director, Occupational Health and Safety

Northern Safety Network Yukon Quality Assurance Program ... · - Leadership for Safety Excellence...

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