Â鶹AV

Â鶹AV.CA / University response to asbestos report

Recommendations & Response

Summary of Internal Audit Findings and Recommendations & Task Force Response

The high-level findings of the Internal Audit (IA) investigation and the 25 recommendations in the full report are summarized below. A single source cannot be definitively determined for the uncontained asbestos detected. Rather, several contributing factors could explain the presence of asbestos fibers. 

The findings and recommendations are followed by a summary of the Task Force action items developed to ensure that the recommendations are fully and completely implemented. While the recommendations in the Internal Audit report stem from the specific events at the Macdonald Campus, they often have broader implications. Therefore, the Task Force response looks at improving asbestos management and processes across the University.

Overarching recommendation

Internal Audit recommended process improvements to enhance Â鶹AV's asbestos control processes. As well, IA also recommends that Management should:

  • Promptly conduct a thorough review of asbestos monitoring mechanisms within current construction and renovation projects involving the potential presence of asbestos, to ensure lessons learned from this incident are applied to these projects at Â鶹AV, and
  • Communicate the results of the review and its corrective actions.

Task Force response

Â鶹AV’s Project Management Office (PMO) has worked with the Task Force to list all current construction projects that may involve work in the presence of asbestos. Each project was reviewed to identify specific areas of concern, such as spaces shared between construction and Â鶹AV building occupants, that were highlighted in the IA report.

A review of all ongoing construction projects has confirmed that safety precautions to tackle issues similar to the ones outlined in the investigation report are satisfactory. Â鶹AV staff such as tradespeople or technicians are being told to pause any work involving materials that may contain asbestos if they do not know whether asbestos is present. An appropriate level of project management oversight has been confirmed.

Internal Audit Report findings and recommendations FMAS-01 and FMAS-02

Building users had great difficulty making their concerns about dust heard; the treatment of concerns differed from the process laid out in Â鶹AV’s asbestos response protocol.

Improve communications processes and eliminate silos among stakeholders; review asbestos response protocol to better coordinate and respond promptly to requests; increase awareness of protocol.

Task Force response

In buildings where asbestos is present, occupants should know when and how to report concerns (such as the presence of new dust, or damaged building materials).  The response should be prompt and problems fixed in a timely fashion.

Actions

  • The Task Force will work with Facilities Management and Ancillary Services (FMAS) and  Environmental Health and Safety (EHS) to establish clear reporting, communication and escalation processes.
  • These processes will be documented and posted on the EHS website.
  • Expanded EHS training and awareness campaigns will ensure that all members of the community are aware of any processes that impact them.

Internal Audit Report findings and recommendations AES-01

A biosafety cabinet was moved without being decontaminated and without informing Â鶹AV’s Environmental Health and Safety unit; construction debris on the cabinet later tested positive for asbestos in one test and negative in a second test.

Ensure Faculty members are aware of established safety protocols.

Task Force response

The moving of the biosafety cabinet raises larger concerns about how well members of the community are aware of, understand and comply with established safety protocols.

Actions

The Task Force will work with Deans, the Project Management Office (PMO), and the University Health and Safety Committee (UHSC) to ensure:

  • Safety protocols are discussed with building occupants when a construction project starts.
  • Principal Investigators receive initial training on safety protocols that is regularly updated.
  • A university-wide awareness campaign is launched, that includes education on the University’s existing framework for responsibility in terms of safety (the Internal Responsibility System).
  • Academic and administrative supervisors should be empowered to enforce disciplinary measures in the case of blatant disregard for safety protocols.

Internal Audit Report findings and recommendations PMO-01, PMO-02, PMO-03

The General Contractor (GC) sometimes did not comply with the obligations regarding asbestos in the contract. It did not employ a qualified safety officer. As well, it did not share inspection reports from the CNESST, Quebec’s workplace health and safety organization, with the University.

Reinforce vigilance of Project Managers overseeing the GC to ensure it fulfils contractual obligations, including health and safety mechanisms such as the presence of a qualified safety officer. Ensure that CNESST inspection reports are provided to Â鶹AV.

Task Force response

This recommendation calls for a closer oversight of several areas of work for General Contractors.

Actions

  • The Task Force will review, with PMO, Procurement Services and Legal Services, how to strengthen contractual obligations of General Contractors (including an obligation to share any CNESST reports with Â鶹AV).
  • The Task Force will also work with PMO to review standard operating procedures Project Managers use to oversee General Contractors, to ensure that contractual obligations are fulfilled throughout the project.

Internal Audit Report findings and recommendations PMO-05, PMO-06, PMO-07

Specific logistical issues encountered during the construction projects in the Raymond building included construction workers and Â鶹AV building users sharing spaces.

  • Construction staff transported construction materials and waste from Raymond through Macdonald-Stewart to the loading dock and elevator.
  • The sharing of space resulted in looser access to the construction site and may have led fume hoods in room R1-038 to pull in construction dust.
  • Ongoing cleaning may not have been done in a shared space that had not formally been handed over (delivered) to the University.

Seal off or segregate construction from occupied areas; if shared space is required, implement rigorous safety and monitoring procedures. Ensure that processes and documentation required to hand over a space to Â鶹AV are complete before allowing users to occupy the space.

Task Force response

Several of the logistical issues are choices made at the time of project design and development, typically in order to minimize the disturbance to academic activities.

Actions

  • The Task Force will work with PMO to draft principles to be followed in future projects to minimize risk conditions related to project design and development.
  • The principles will be validated with senior administration to ensure that:
    • there is alignment with the academic mission of the university, and
    • senior academic leaders can support decisions that are dictated by safety principles, despite the potential negative impacts on academic activities.

Internal Audit Report findings and recommendations PMO-04, PMO-08, PMO-09, PMO-10

Tighter project management of construction work could have prevented certain situations. For example, inconsistent air circulation that may have spread potentially contaminated dust from the construction area to occupied areas. The scale of the construction projects expanded significantly but the capacity of the external Project Manager to deliver the mandate was apparently not reviewed.

Ensure Â鶹AV’s Project Management Office adopts tighter oversight of external Project Managers; ensure continuous adequate air circulation within construction sites. Review the Project Manager’s capacity to deliver if the scope of its mandate expands significantly.

Task Force response

The expansion of workload for the external Project Manager may have made it difficult to fully oversee the Raymond construction. The PMO needs to ensure the scope of the Project Manager’s mandate is appropriate.

Actions

  • The Task Force will work with PMO to understand issues related to increased and potentially excessive workload of internal and external project managers, the reality of the recruitment market in the field of project management, and the demands placed on PMO stemming from the current slate of projects.
  • The university will ensure that the capacity to manage projects that is available within PMO (through internal and external PMs) matches the demands in terms of construction projects.

Internal Audit Report findings and recommendations PMO-11, PMO-12

Â鶹AV’s default project risk contingency of 10% of construction expenses may have been too low.

Implement an enhanced risk management process that considers contingency project-by-project. Prioritize projects requiring a more robust approach, such as those that may involve work in the presence of dangerous materials.

Task Force response

Current University practices for risk management for renovation projects may not be sufficient to properly tackle the complexities of large projects in the presence of asbestos.

Action

  • The Task Force will work with PMO, Risk Advisory and Insurance Services and Legal Services to review current risk assessment frameworks, benchmark with peer universities and organizations, and propose potential changes in the way we approach risk and contingencies.

Internal Audit Report findings and recommendations PMO-13

Industrial hygiene consultants only monitored asbestos work involving high-risk conditions. However, CNESST reports documented problems with moderate-risk work; increased monitoring would have been appropriate. 

Ensure industrial hygiene consultants supervise the full scope of construction work, including moderate- and low-risk asbestos work if needed.

Task Force response

Industrial hygiene consultants are playing a key safety oversight role in our construction projects. An expanded surveillance mandate may have, in the case of the Raymond building project, led to earlier alerts regarding issues.

Action

  • The Task Force will mainly work with PMO and EHS to review the mandates of the industrial hygiene consultants in all our projects and expand mandate where necessary compatible with the risk level of each project.

Internal Audit Report findings and recommendations EHS-01

The roles, responsibilities and authority of Â鶹AV’s Environmental Health and Safety unit (EHS) vis-à-vis other units involved in asbestos management are not clearly defined.

Formalize clear lines of authority for EHS and other asbestos management stakeholders; review the current asbestos policy and submit to governance for approval.

Task Force response

The investigation report reveals that the mandate and authority of EHS may not allow its health and safety professionals to exercise the appropriate level of control over projects of all types. There can also be a lack of compliance with EHS’s decisions.

Actions

  • The Task Force will examine EHS’s authority and mandate to strengthen its role and authority.
  • The Task Force will recommend structures to be put in place to ensure that non-compliance with EHS directives has consequences, such as impact on performance evaluations or disciplinary measures.
  • The Task Force will work closely with EHS, its parent unit Campus Public Safety, as well as the Vice-Principal (Administration and Finance) and the Secretariat to ensure proper governance mechanisms are put in place and enforced.

Internal Audit Report findings and recommendations EHS-02, EHS-03, EHS-04

Asbestos-related policy and procedures are not up to date; the updated asbestos management plan is not deployed; the asbestos registry is not complete. A lack of EHS capacity delayed testing for asbestos.

Develop a comprehensive plan for monitoring compliance with process controls. Ensure EHS capacity is sufficient at the Macdonald Campus and across Â鶹AV in light of EHS’s revised mandate.

Task Force response

The investigation report points out that the university’s asbestos management program is not completely clear, and the asbestos policies currently posted on our website do not fully correspond to current practices. The process should be transparent and known to members of the Â鶹AV community.

EHS has been experiencing staffing issues over the last months. The University should deploy all efforts to ensure that staffing targets are met.

Actions

  • The Task Force will work with EHS to ensure that policy and practices are aligned, and that all members of the community are aware of the updated policy.
  • The Task Force will work with EHS to develop a full compliance plan to ensure that compliance with the policy is monitored and tracked, reported on and that any infractions are followed up on appropriately. This may lead to the need for additional resources in EHS (see the recommendation below).
  • The Task Force will work closely with EHS, Campus Public Safety and the VP (Administration & Finance) to ensure that EHS staffing is sufficient to carry out its (potentially expanded) mission and mandate.

Internal Audit Report findings and recommendations EHS-05, EHS-06

The process to coordinate training on asbestos could be streamlined. The University’s existing safety committees can further promote health and safety.

Improve coordination and communication of training; adopt a comprehensive approach to improving health and safety culture.

Task Force response

The report points out members of the community can lack awareness of safety protocols. There are weaknesses in the health and safety culture of the University, despite many prior efforts to improve this situation. As well, different members of the community have distinct needs for health and safety training. These needs depend both on their roles (e.g., as a principal investigator) and on their context and circumstances (e.g., the start of a construction project in their building).

Action

  • The Task Force will work with EHS and communications units within FMAS and centrally to create yearly plans for training and awareness. The plans will be designed to address the main roles and situations of members of the community.

Internal Audit Report findings and recommendations EOC-01, EOC-02, EOC-03

Â鶹AV’s Emergency Operations Centre (EOC) had difficulty gathering complete, timely and accurate information. The Policy Group, made up of members of the senior administration, was not activated to provide the EOC with strategic direction. Members of the community wanted EOC communications that were more frequent, interactive, and personal.

Clarify EOC roles and set clear expectations for activations; review criteria to activate Policy Group; review frequency and method of communication delivery.

Task Force response

The report points to issues that arose during the EOC mobilization in the winter of 2023 for the Macdonald Campus. EOC has examined some of these issues (e.g., communications planning, onboarding mechanisms for Subject Matter Experts) in its after-action debrief.

Actions

The Task Force will work with the Office of Emergency Management to ensure that:

  • Roles and responsibilities for EOC members are clear and known.
  • Criteria to activate groups involved in the University’s emergency response are revised.
  • Principles and guidelines are in place to ensure the effectiveness of EOC communications.

Note: This website contains summaries of the Macdonald Campus Asbestos Investigation Report and the Action Plan of the Task Force, which have been abridged to provide an overview. For the complete context, findings and recommendations, as well as the response to address the recommendations, please read the full report and the Task Force Action Plan.

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