Health and Safety Management System

Table of Contents

  1. Introduction
  2. General Principals
  3. Organizational Structure and Staff
  4. Training
  5. Performance Standards
 1. Introduction   
  Under Provincial Health and Safety legislation, the Occupational Health and Safety Act, (the OH&S Act), places the onus for compliance with the legislation on the key players

within an organization. As such, the legislation spells out key, defined responsibilities

for each of these individuals, forming the Internal Responsibility System (IRS). This

Internal Responsibility System provides the building blocks for an effective Health and

Safety Management System.

The key players in the Internal Responsibility System at Queen's University are:

  • The Board of Trustees;
  • The Office of the Principal;
  • The Deans of the various Faculties;
  • Directors, Department Heads, Principal Investigators and Supervisors; and
  • Employees

The key duties for each of these individuals are outlined and discussed in further detail later in this document. Please refer to Appendix 1 (PDF*, 19 KB) for a schematic illustration. 


The management of health and safety is not an optional extra or "Bolt-on" to existing management activities. In order to make our health and safety management system  successful, it has to be fully integrated into all other management activities.

Health and Safety issues must be included in all financial planning activities, therefore they need to be accounted for and be integrated into the yearly budgetary process. Each level within the organization has its own obligations and responsibilities to those working with them, for them and to those who work under their direct supervision.

1.3 The safety standards at Queen's University must, at a minimum, meet the requirements of any applicable piece of legislation or code of practice, as set by the various regulatory agencies.
1.4 Students leaving Queen's University should take with them the knowledge and the attitude, which integrates and accepts good health and safety practices as normal in their everyday work activities. This standard can only be met if the faculty and staff within the organization set high personal standards, lead by personal example and ensure that safe work practices are routine in everyday activities.

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General Principals

2.1 Responsibilities of the University

It is the ultimate responsibility of the Board of Trustees of Queen's University, through the University's senior administration, to ensure that all regulatory requirements are met and appropriate standards applied.

In order for this to be implemented, the senior management group is required to demonstrate both leadership and commitment to the full integration of health and safety into every applicable University policy and practice. Safe working policies must be agreed to and instituted following effective consultation within all levels of the organization and through legislated forums (ie Joint Health and Safety Committees).

As is discussed in further detail later in this document, the responsibility for ensuring adherence to University policies and procedures, which are a compliance requirement under the applicable regulations, rests with all employees of the University. It is of primary importance that all Department Heads and Principal Investigators ensure that the staff they are directly accountable for work in compliance with all applicable Acts and Regulations and are provided with the necessary training.

Due to the unique nature of a university workplace, it is of prime importance that Principal Investigators realize that they have all of the duties and responsibilities of employers and supervisors as detailed by the OH&S Act, with respect to their contract staff.

A formal auditing system should be put into place to monitor and review overall performance and commitment. The results of these audits must be reviewed by the appropriate committee, the senior administration of the University and preferably by the Board of Trustees.

In the event that an employee or student of the University is found to be working in an unsafe manner, contrary to University policy and in contravention of the applicable regulation, a system must be in place to take corrective action. Dangerous working conditions must be stopped by the appropriate University Official and must be dealt with in accordance with the provisions spelled out in the OH&S Act and/or other applicable codes of practice or legislation.

2.2 Health and Safety Policy
  Queen's University has in place an Occupational Health and Safety Policy in accordance with section 25(2)(j) of the OH&S Act. Under provincial legislation, this policy must be reviewed on a yearly basis and re-endorsed by the Board of Trustees. In order to make the policy a reality, it needs to be implemented in all departments on campus and be supported by a strong Health and Safety Management System.

The success of the policy depends on the effectiveness of the implementation program and the adequacy of the system to communicate it to the entire organization. Section 3.0 of this document, entitled the "Organizational Structure and Staff" fully details how the health and safety management system at Queen's is organized and communicated to the Queen's community. 

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Organizational Structure and Staff

  In developing the organizational structure to support a safety management system, the
University has taken into account:
  • The formal delegation of responsibility and authority for health and safety to specific individuals, as low in the organizational hierarchy as possible;
  • The formal consultation processes which are in place including all trade unions, staff associations and the joint health and safety committees;
  • The need to provide all staff with the necessary information surrounding the hazards associated with their job tasks and the control measures needed to minimize the hazard;
  • The need to provide proper training to all staff specific to health and safety; and
  • The provision of technical resources through the Department of Environmental Health and Safety.
3.1 Management Structure for Health and Safety

Heads of Departments

Under the OH&S Act specific duties and legal obligations are delegated to persons who have direct authority over staff. These obligations include:

  • Use of personal protective equipment, protective devices or clothing;
  • Advising staff of the existence of any potential or actual danger to the health and safety of a worker;
  • Provide staff with the proper training and written instructions as to measures and procedures which must be followed to protect the employees;
  • and Ensuring staff within the department work in accordance with set instructions, procedures and guidelines and in compliance with applicable guidelines and regulations.

Although a number of functions surrounding the performance of these specific duties and legal obligations can be delegated by the Head of the Department, the responsibility to ensure compliance with applicable guidelines and regulations still rests with this individual. Department Heads and Directors must ensure compliance with the applicable Act or Regulation is met through: Although a number of functions surrounding the performance of these specific duties and legal obligations can be delegated by the Head of the Department, the responsibility to ensure compliance with applicable guidelines and regulations still rests with this individual. Department Heads and Directors must ensure compliance with the applicable Act or Regulation is met through:

  • The provision of necessary information, instruction and training to enable department staff to safely perform their jobs;
  • The introduction and maintenance of measures or systems designed to identify, monitor and control risks;
  • Maintenance of appropriate records sufficient to demonstrate compliance with their duties and obligations; and
  • The proper provision of supervision of all undergraduate and graduate students.

Academic and Supervisory Staff

Both academic and supervisory staff shall conduct their activities and ensure that those activities over which they have control are conducted in a safe manner and in accordance with the University's policies, codes of practice and any other applicable legislation.  Coordination with the Department Head and Departmental Safety officer is needed to ensure that all responsibilities are met both from a policy and legislative perspective.

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3.2 Specialized Health and Safety Resources
  Joint Health and Safety Committees

Queen's University has a number of local Joint Health and Safety Committees which function as advisory bodies, dealing with health and safety issues affecting employees at the University. The committees are composed of equal representation of employees from both management and bargaining unit staff. Together they are committed to improving health and safety in the work place.

The committees are a legal requirement under the OH&S Act and are designed to stimulate discussion on workplace health and safety issues, recognizing workplace risks and making recommendations on how they can be corrected. Each committee is required under legislation to meet at least once every three months and to conduct workplace inspections monthly. In a workplace the size of Queen's University a portion of the workplace must be covered monthly, with the entire University being inspected at least once per year.

For a complete overview of the duties and functions of the Joint Health and Safety Committees, please contact the Department of Environmental Health and Safety for further details.

Departmental Safety Officers

Queen's University has a system in place where each department has an appointed Safety Officer. These individuals are the main communication link between their administrative unit and the Department of Environmental Health and Safety. The Safety Officer is responsible for conducting inspections, following up on any deficiencies noted during internal or Ministry of Labour inspections, investigating incidents within the department, as well as keeping the Head of the Department informed of all safety related issues. The Safety Officer works in conjunction with the local Joint Health and Safety Committee

 Department of Environmental Health and Safety

The Department of Environmental Health and Safety is a unit, comprised of dedicated staff with expertise in various areas, which acts as a resource to the Queen's community on health and safety related issues.

Headed by a Director, the unit takes a lead role in advising the University at large on a wide range of health and safety issues and undertakes a central co-ordinating role for the implementation of health and safety programs. The department is key in developing the

University's safety related policies, plans and is key in setting up and maintaining the University's safety management system.

Expertise within the unit includes Fire Prevention, Radiation Safety, Biohazard Safety, Task design Ergonomics, Indoor Air Quality, Hazardous Material Handling and Disposal, and Environmental Compliance. The unit provides in house safety related training and works in a co-operative, consultative manner within the University community. The emphasis is on preventing incidents from occurring through a pro-active approach.

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4.0 Training
  An integral part of any health and safety management system is training related to the hazards associated with the workplace.

The University, at the present time, provides faculty staff and students with training directly related to the immediate workplace conditions. This training must be viewed as an on going integral part of the health and safety management system.

The responsibility to ensure that all staff working within a unit have received the appropriate training, both that which is prescribed by legislation and that which is University based, rests with the direct supervisor and ultimately with the Department Head for the given unit.

The type of training, which needs to be provided, includes:

Training prescribed by legislation such as WHMIS and Radiation Safety;

  • Hazard identification skills;
  • Proper use of personal protective equipment;
  • Health and safety policy/ procedure training;
  • Proper techniques to be used in carrying out workplace procedures; and
  • Duties, rights and responsibilities under the applicable legislation.

The most appropriate, knowledgeable and competent person available should carry out delivery of the training. The immediate supervisor should deliver much of the training, as that person has direct knowledge of many of the hazards associated with the work.  Additional training is available from the Department of Environmental Health and Safety and various other sources.

5.0 Performance Standards
  In developing the management system to accompany the University's Health and Safety Policy, it is recognized that neither of these two are static entities. Both elements are living entities, which are required to be flexible to respond to the ever changing legislative requirements as well as the reality of the changing elements of a dynamic workplace. The types of issues, which arise in today's workplace environment, must be dealt with from both a legislative requirement perspective as well as addressing the true risks associated with the work activity. The primary way of uncovering these issues is through an active inspection, monitoring and audit process.

Each department on campus is required to ensure that the appropriate performance standards are established within the work unit, that they are adhered to and fully implemented. A system of record keeping of the monitoring is required and must be kept up to date, including details of what corrective actions are implemented. The Department of Environmental Health and Safety, worker representatives from the Joint health and Safety Committee, as well as outside regulatory agencies, conduct periodic checks of this system.

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5.1 Risk Assessments
  It is the responsibility of the Heads of Departments, aided by the Safety Officer to conduct risk assessments and satisfy themselves that the risk assessments are:
  • Completed;
  • Completed to consistent and reasonable standards;
  • Relate to the current work performed within the department;
  • Are reviewed on an annual basis; and
  • are supported by adequate and up-to-date records.

The Department of Environmental Health and Safety can also be contacted for guidance and assistance.

5.2 Inspections, Monitoring and Auditing
  In order to verify and document the functioning and effectiveness of safety programs and policies, a system of active and reactive monitoring must be maintained.

Under the OH& S Act, a workplace the size of Queen's must have a portion of it inspected monthly by a worker member of a Joint Health and Safety Committee, and the entire workplace must be inspected yearly. The Canadian Nuclear Safety Commission also requires compliance audits, as do many of the other regulatory agencies, as detailed by their respective pieces of legislation. To effectively support these requirements, regular departmental inspections must be conducted.


The principle behind conducting an inspection is to conduct a physical check on a department to identify the presence of hazards requiring control measures to be put into place. Inspections at the departmental level should enable a Department Head to establish whether the standards required by the University and the legislation are being complied with and are fully implemented. If compliance issues exist, it is a requirement for the Department Head to ensure that the necessary steps are taken to correct any deficiencies.

The Department of Environmental Health and Safety can also be contacted for advice, direction and training in this area.


As a second level check on the effectiveness and efficiency of the management system, routine proactive monitoring should occur. The Joint Health and Safety Committee members should conduct this check as they complete the required legislative checks on the IRS.

Unfortunately no matter how effective a safety management system is put into place, serious occurrences do occur from time to time. When these situations arise, a reactive monitoring system needs to be used. This allows for a consistent follow up to these occurrences, determining the true root cause and facilitating the implementation of the appropriate corrective measures.

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In these situations, the Department of Environmental Health and Safety needs to be contacted so that they can assist the department in finding the root cause and suggest corrective action to prevent a re-occurrence. Other people to contact include the certified members of the local Joint Health and Safety Committee, the supervisor and Safety Officer for the Department.

In the event of a fatality or critical accident as defined by the OH&S Act, the Ministry of Labour will also be notified and will, in most cases, investigate.


The audit system provides another check on the overall Occupational Health and Safety System at the University and will be performance based. The audit will be carried out on various departments by the Department of Environmental Health and Safety in conjunction with Internal Audit and will measure the level of compliance by the various departments with this management system and the overall University Policy on Occupational Health and Safety.

This achieves two objectives:

  • The Board of Trustees and the Senior Administration have an overview of each department's level of compliance with the required legislation and policies of the University, and
  • Any shortcomings are clearly identified, allowing Department Heads and Directors to set specific priorities for addressing shortcomings in resource allocations and other areas, which directly impact on their program delivery.  
5.3 Review
  On a yearly basis, the Department of Environmental Health and Safety is required to produce a formal report on the level of compliance by the University with the legal requirements of the applicable health and safety and environmental legislation. This report is produced by request of the Board of Trustees. 

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