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Appendix II
MN&P Safety Program Audit Evaluation Table

1.0 POLICY AND COMMITMENT

1.1 Policy and Commitment Statements

Expectations: The company shall have a policy approved and endorsed by senior management (the Policy). It should include goals and objectives and commit to improving the performance of the company.

References:[1]
OPR-99 sections 4 and 7
CSA Z662-07 Clause 10.2.2
CLC Part II 125(1)(d)(i)-(ii), 125(1)(z.09)

Assessment:
M&NP has endorsed its Operator’s Environment, Health and Safety (EHS) policy, EHS Management System (MS), performance standards and safety action plan which outline its commitment to ensuring safety for personnel and the public.

The EHS policy includes the following principles

  • Accountability;
  • Stewardship;
  • Standards;
  • Performance; and
  • Communication.

The EHS MS describes how employees and contractors are expected to meet the desired level of EHS performance for the following elements:

  1. Roles, responsibilities and accountabilities;
  2. Risk management;
  3. Emergency Preparedness & Response;
  4. Compliance management;
  5. Supplier, Contractor and Partner Relationships;
  6. Stewardship and community relations;
  7. Goal setting and performance measurement;
  8. Incident reporting and investigation; and
  9. Assessment and management system review.

Based on interviews and documents reviewed, the Board verified that M&NP has formally endorsed its Operator’s EHS MS and that the commitment to managing its safety hazards and risks is demonstrated at all levels within the organization.

Compliance Status: Compliant

[1] Each “Reference” in this table contains specific examples of the “legal requirements” applicable to each element but are not necessarily a complete list of all applicable legal requirements.

2.0 PLANNING

2.1 Hazards Identification, Risk Assessment and Control[2]

Expectations: The company shall be able to demonstrate a procedure to identify all possible hazards. The company should assess the degree of risk associated with these hazards. The company should be able to support the rationale for including or excluding possible risks in regard to its environment, safety, integrity, crossings and awareness and emergency management and protection programs (management and protection programs). The company should be able to implement control measures to minimize or eliminate the risk.

References:
OPR-99 sections 4(2) and 47
CSA Z662-07 Clause 10.2
CLC Part II 125(1)(s)(z.03)-(z.05), 125(1)(z.13)-(z.16)
COSHR 19.1(1), 19.3(1)-(2), 19.5(1)-(5)

Assessment:
As part of an Operations and Maintenance (O&M) Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EHS MS.

The Operator incorporates a Risk Inventory and Job Safety Analysis (JSA) to assess EHS risk. The risk inventory method involves discussions with EHS, Operations, Maintenance, and other site personnel around specific scenarios. For each risk scenario, the team discusses how workers could be injured or the environment damaged and then they discuss and evaluate the adequacy of existing controls. The JSA method integrates risk assessment and risk control to a particular task completed in order to identify appropriate roles at specific locations. The Operator documents hazards using Job Hazard Assessments (JHA); Hazard Identification and Reporting forms and Job Observation Checklists.

The Operator conducts risk assessment workshops annually to ensure the ongoing validity of identified risks and the possible identification of new ones. Prior to the workshop, EHS personnel obtain input from across the organization by interviewing a broad range of staff. This feedback is used as the basis for the workshop. These assessment workshops are designed to establish a forum/avenue to identify and evaluate EHS risks.

Another element of the EHS program involves a contractor health and safety management performance standard. It provides guidance for the registration, selection and oversight of all contractors performing work on the M&NP system and facilities. Implementation of the program ensures contractor safety expectations are met and risks are successfully managed. The contractor develops its H&S work plans prior to the start of work. Management conducts a review to ensure adequate internal and external oversight controls are part of the project review.

The Operator was able to demonstrate that EHS hazard identification, risk assessments and controls are being conducted throughout the organization and integrated into the appropriate aspects of the operation.

Compliance Status: Compliant

[2] Hazard: Source or situation with a potential for harm in terms of injury of ill health, damage to property, damage to workplace environment, or a combination of these. Risk: Combination of the likelihood and consequence(s) of a specified hazardous event occurring

2.2 Legal Requirements

Expectations: The company shall have a verifiable process for the identification and integration of legal requirements into its management and protection programs. The company should have a documented procedure to identify and resolve non-compliances as they relate to legal requirements which includes updating the management and protection programs as required.

References:
OPR-99 sections 4, 6 and 47
CSA Z662-07 Clause 10.2.2(g)
CLC Part II 125(1)(v)
COSHR 19.1(1)

Assessment:
As part of an O&M Agreement between M&NP and its Operator, the Operator is responsible for developing, implementing and maintaining the EHS MS.

During the audit it was identified that the Operator has developed a process which includes the identification of and status of regulatory requirements and undertakings. An annual review is conducted of Standard Operating Procedures (SOPs) to ensure legislated requirements are met and a gap analysis is conducted by the Operator’s United States (U.S.) based staff to determine any next steps which may be required. Additionally, the Operator’s Canadian EHS staff monitors Canadian Occupational Health and Safety (OHS) legislation and industry best practices with respect to any recent changes that are relevant to operations.

Regardless of the development and intent of the processes described above, the Operator was unable to demonstrate that its processes included all of the Canadian OHS legislation which applied. For example, it was noted during document review and interviews that the Canada Labour Code Part II (CLC Part II) and the Canada Occupational Health and Safety Regulations (COSHR) were not included in any of the reference documents, making it difficult to verify whether the relevant requirements had been identified and integrated into these documents. As another significant example, at the time of the audit, the Operator was not able to demonstrate that it has a process that would meet the requirement to develop and implement a “Violence Prevention in the Workplace” program as required by CLC Part II 125.1(z.16) and COSHR Section 20 which came into effect in 2008 (SOR/2008-148, s. 1 Interviews with the Operator’s Human Resources personnel confirmed that the 'Violence in the Workplace Policy and Program' is currently under development; however, as the program was in the early stages of development, it could not be assessed for adequacy.

As part of its comments on the Draft Audit Report, M&NP indicated that the Manager, Regulatory Affairs is the primary point of contact with the NEB with regard to any compliance issues or changes to regulatory requirements. Upon receiving notification/correspondence from the NEB, the Manager, Regulatory Affairs forwards this information within the company as deemed appropriate. Safety compliance issues and identified gaps are tracked within the appropriate management team (lead by the Area Manager for operations related issues and the Project Manager for capital project related issues) as well as by the EHS Department.

The Operator did not demonstrate that it has an effective and fully-implemented process to identify and integrate all appropriate occupational health and safety legislation into its Safety Program.

Compliance Status: Non-compliant

2.3 Goals, Objectives and Targets

Expectations: The company should have goals, objectives and quantifiable targets relevant to the risks and hazards associated with the company’s facilities and activities (i.e. construction, operations and maintenance). The objectives and targets should be measurable and consistent with the Policy and legal requirements and ideally include continual improvement and prevention initiatives, where appropriate.

References:
OPR-99 section 47
CSA Z662-07 Clause 10.2.2(h)(ii)
COSHR 19.1(1)

Assessment:
As part of an O&M Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EHS MS.

The Operator has a system in place to identify EHS goals and integrate them into action plans for corporate and individual assessments. Action plans and objectives are set out by the Vice Presidents of the various divisions participating in the Operations Committee, EHS Committee, as well as regional management and staff personal safety action plans. These committees provide reports and updates to senior management to provide a clear picture of the work of the committees in relation to the established goals.

EHS goals, targets and objectives have been identified for all staff and are included in individual job descriptions. The employees’ objectives are discussed at the beginning of the year, again at least once during the year and a third time at the end of the year when the past year’s performance is evaluated and objectives are established for the next year. EHS performance is included in the overall employee objectives and employees are provided recognition for meeting their EHS performance objectives (known as “Short Term Incentive Programs”).

The audit identified that goals, objectives and targets, while managed appropriately, only marginally meet the present minimum requirements to be compliant and could be improved to address issues more relevant to M&NP operations in Canada. Particularly, it was noted that the goals focussed on broader regional issues such as compression which is more relevant to the Northeastern (NE) United States (U.S.) facilities where the majority of this region’s activities are located. Presently there are no compression facilities in Canada; therefore, the goals do not fully reflect the NEB facilities and related activities.

Although the Operator was able to demonstrate that it has set objectives and targets relevant to its hazards and risks associated with the company’s facilities and activities and has integrated them into individual and corporate performance measures, the Board recommends that these goals and targets be reviewed to verify their suitability to the Canadian operational requirements.

Compliance Status: Compliant with Recommendation

3.0 IMPLEMENTATION

3.1 Organizational Structure, Roles and Responsibilities

Expectations: The company shall have an organizational structure that allows its management and protection programs to effectively function. The company should have clear roles and responsibilities, which may include responsibilities for the development, implementation and management of the management and protection programs.

References:
OPR-99 section 47
CSA Z662-07 Clauses 10.2.1 and 10.2.2(b)
CLC Part II 125(1), 125.1, 134.1, 135(1)

Assessment:
The Operator has established an EHS Management Team with specific accountability for EHS related issues and programs.

Overall accountability for EHS issues is maintained by the EHS Committee (EHSC) which is comprised of senior personnel. The EHSC provides regular updates to the Board of Directors.

Lines of reporting for EHS issues within the Operator’s management structure are clearly outlined, and include reporting routes from the Vice President, Operations Northeast (NE) Transmission; Manager, NE-Health & Safety and EHS Support Specialist. The other line of reporting includes the Director EHS, Houston. The Board reviewed copies of employee job descriptions to confirm that specific EHS responsibilities and accountabilities are identified.

The Operator was able to demonstrate that is has an organizational structure that allows it to effectively manage its internal EHS MS.

Compliance Status: Compliant

3.2 Management of Change

Expectations: company shall have a management of change program. The program should include:

  • identification of changes that could affect the management and protection programs;
  • documentation of the changes; and
  • analysis of implications and effects of the changes, including introduction of new risks or hazards or legal requirements.

References:
OPR-99 section 6
CSA Z662-07 Clause 10.2.2 (g)
CLC Part II 125.(1)(z.05)-(z.06)
COSHR 19.5(4), 19.6(2)

Assessment:
As part of an O&M Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EHS MS.

The Operator was in the process of implementing the EHS MS Management of Change Performance Standard 2.7. This standard includes a process for identifying, assessing and implementing approved procedural changes. There are also MOC related initiatives in progress such the process to review all SOPs for the Operator against all US and Canadian regulatory requirements and best practices. EHS is leading the process with support of senior management, and regional subject matter experts.

At the time of the audit, the Operator did not provide evidence to demonstrate a fully-implemented MOC program that identifies documents and analyzes changes that could affect the EHS MS, including introduction of new risks, hazards or legal requirements.

Compliance Status: Non-compliant

3.3 Training, Competence and Evaluation

Expectations: The company shall have a documented training program for employees and contractors related to the company’s management and protection programs. The company shall inform visitors to company maintenance sites of the practices and procedures to be followed. Training requirements should include information about program-specific policies. Training should include emergency preparedness and environmental response requirements as well as the potential consequences of not following the requirements. The company should determine the required levels of competency for employees and contractors. Training shall evaluate competency to ensure desired knowledge requirements have been met. Training programs should include record management procedures. The training program should include methods to ensure staff remains current in their required training. The program should include requirements and standards for addressing any identified non-compliances to the training requirements.

References:
OPR-99 sections 28, 29, 30(b), 46, 47 and 56
CSA Z662-07 Clause 10.2.2(c)
CLC Part II 124, 125(1)(q), 125(1)(s), 125(1)(z), 125(1)(z.01), 125(1)(z.03)
COSHR 10.14, 11.5(2), 11.11, 12.10(1.1)(a)(ii), 12.10(1.2), 12.15, 13.11, 14.23, 17.6(1), 20.10, 19.1(1), 19.2(2), 19.6

Assessment:
As part of an O&M Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EHS MS.

The Operator has a safety training matrix for employees assigned to operating and maintaining the M&NP pipeline. This matrix consists of a list of core safety training courses and the frequency for renewal. Employees are provided with notice and reminded of any updates to this matrix should additional training requirements be identified or should the existing curricula change. Also, some of the EHS training is offered online. The Human Resources Orientation Checklist includes all relevant EHS courses and managers are required to sign-off. Document review confirmed that training for the technical staff is being managed. Hard copies of training records are maintained by the administrator in the regional offices and electronic versions are managed at an offsite location (Houston, TX). Managers and employees receive electronic notifications when select training is due to be renewed. There is an annual evaluation on overall performance and the records are maintained by administrative staff.

The Operator was able to demonstrate that it has an adequate and effective safety training program for staff.

Compliance Status: Compliant

3.4 Communication

Expectations: The company should have an adequate, effective and documented communication process(es):

  • to inform all persons associated with the company’s facilities and activities (interested persons) of its management and protection programs policies, goals, objectives and commitments;
  • to inform and consult with interested persons about issues associated with its operations;
  • to address communication from external stakeholders;
  • for communicating the legal and other related requirements pertaining to the management and protection programs to interested persons; and
  • to communicate the program’s roles and responsibilities to interested persons

References:
OPR-99 sections 18, 28, 29 and 47
CSA Z662-07 Clause 10.2.2(d)
CLC Part II 122.3(1)-(2), 125(1)(d)-(f), 125(1)(s), 125(1)(z.03)-(z.11), 125(1)(z.14)-(z.15), 125(1)(z.17)-(z.19)

Assessment:
As part of an O&M Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EHS MS.

The Operator was able to demonstrate that it uses various methods for communicating safety requirements with its internal and external stakeholders. Currently, it communicates EHS requirements and issues with staff in the following ways:

  • Safety Stand Down Meetings;
  • Quarterly Employee Meetings and Safety Updates;
  • Daily tailgate meetings;
  • Daily and weekly safety reports;
  • Northeast Region Health and Safety Newsletters;
  • Monthly Safety & Communications Meetings; and
  • Monthly reporting to EHS Corporate group.

Despite the many communication avenues, the Operator did not demonstrate that a formalized communication plan existed within the organization that identifies interested parties and pertinent information required to be communicated.

Although interviews confirmed communication is occurring throughout technical networks and through the means identified above, without a formal communication plan, the Operator cannot ensure that all stakeholders and interested parties are receiving the key information in a timely fashion or by an established and ongoing process. The informal nature of the communication mechanisms does not allow for the demonstration of ongoing adequacy of the communication taking place within the organization.

The Board could not verify that a formalized communication plan exists within the organization that clearly identifies interested parties and pertinent safety information that is required to be communicated in accordance with Board expectations.

Compliance Status: Non-compliant

3.5 Documentation and Document Control

Expectations: The company should have documentation to describe the elements of its management and protection programs-where warranted. The documentation should be reviewed and revised at regular and planned intervals. Documents should be revised immediately where changes are required as a result of legal requirements or where failure to make immediate changes may result in negative consequences. The company should have procedures within its management and protection programs to control documentation and data as it relates to the risks identified in element 2.0.

References:
OPR-99 sections 27, 47 and 56
CSA Z662-07 Clause 10.2.2(e) and (f)
CLC Part II 125(1) (z.03)-(z.06), 125(1) (z.09), 125.1(d)-(e), 125.1(f), 135.1(9)
COSHR 1.5, 2.23, 4.6, 5.17, 5.18, 8.12, 8.14(4)-(7), 8.15, 10.3

Assessment:
As part of an O&M Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EHS MS.

The Operator manages safety related documents in the regional offices. The audit confirmed that there is a comprehensive document management system is in place, which includes processes to control and transmittal tracking of all safety program related documents. Review of the document control process showed that the system is undergoing continual improvement including monitoring, evaluation and updating of program documents when required. The Operator was able to demonstrate that it has adequate documentation control procedures in place to ensure the EHS MS provides the appropriate level of guidance to employees.

However, during the document review, the Board identified version control issues with selected safety program documents. For example, CSA Z662-03 was referenced in procedures throughout the Operations and Maintenance Manual. That is not the most current version of that standard. However, there was no evidence suggesting that the outdated reference was indicative of a systemic issue as the Integrity Management Program Manual and the Emergency Preparedness Manual referenced the CSA Z662-07.

The Operator was able to demonstrate that is has adequate documentation and controls in place to ensure that the EHS MS provides the appropriate level of guidance to employees. Due to the issue of outdated CSA references, the Board recommends that the Operator update the Operations and Maintenance Manual to reflect the current version of the CSA standard. This reference update ensures that users of the document can trace a requirement as referenced in the manual and obtain the most up-to-date requirements.

Compliance Status: Compliant with recommendation

3.6 Operational Control - Normal Operations

Expectations: The company should establish and maintain a process to develop, implement and communicate mitigative, preventive and protective measures to address the risks and hazards identified in elements 2.0 and 3.0. The process should include measures to reduce or eliminate risks and hazards at their source, where appropriate.

References:
OPR-99 sections 27-49
CSA Z662-07 Clauses 10.2.2(f) and 10.3.1
CLC Part II 125.(1), 125.1
COSHR 19.1(1)

Assessment:
As part of an O&M Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EHS MS.

During the audit, it was confirmed that the risk assessment and Job Hazard Assessment include various mitigating measures to ensure operational control is maintained. The Operator uses these mitigating measures to form the basis of the operational procedures. Spectra is working on a SOP Harmonization Project which is in a transition phase. The SOP Harmonization Project is for Spectra Energy Transmission’s U.S. Operations and Spectra’s Canadian Operations in the Maritimes.

At the time of the audit, the Health and Safety Standards Manual contained procedures for tasks typically encountered by personnel and includes the Personal Protective Equipment requirements. The procedures reference and acknowledge compliance with applicable legislation and with industry best practices where applicable.

An Operations Control Table of risks and hazards is being developed to provide consistency across the business units. Once developed, the table will be used in conjunction with the EHS Risk Registry Guide which provides a centralized summary of risk scenarios for review by Business Unit Leadership. This summary is applied when setting priorities and allocating resources to adequately manage the EHS element of operational risk.

The Operator was able to demonstrate that there is a process to reduce or eliminate hazards as appropriate.

Compliance Status: Compliant

3.7 Operational Control - Upset or Abnormal Operating Conditions

Expectations: The company shall establish and maintain plans and procedures to identify the potential for upset or abnormal operating conditions, accidental releases, incidents and emergency situations. The company shall also define proposed responses to these events, and prevent and mitigate the likely consequences and/or impacts of these events. The procedures must be periodically tested and reviewed, and revised where appropriate (example, after emergency events).

References:
OPR-99 sections 32, 35 and 52
CSA-Z662-07 Clause 10.3.2
CLC Part II 125(1)(o)
COSHR 17.4, 17.5, 19.1(1)

Assessment:
As part of an O&M Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EHS MS which encompasses the procedures for addressing upset conditions.

The Operator has developed and implemented an emergency preparedness and response plan which includes safety issues. Interviews and document review verified that personnel safety issues are identified and incorporated into emergency procedures such as the evacuation procedures. Emergency evacuation drills and mock exercises are held on a regular basis. Safety issues are identified and incorporated into the exercises and review and learn discussions for incorporation into the procedures as part of the continual improvement of the program. For more details on the Emergency Preparedness and Response (EPR) Plan as it relates to the expectations of OPR-99, see Appendix IV: M&NP EPR Program Audit Evaluation Table.

Compliance Status: Compliant

4.0 CHECKING AND CORRECTIVE ACTION

4.1 Inspection, Measurement and Monitoring

Expectations: The company shall develop and implement surveillance and monitoring programs. These programs should address contract work being performed on behalf of the company. These programs should include qualitative and quantitative measures for evaluating the management and protection programs and should, at a minimum, address legal requirements as well as the risks identified as significant in elements 2.0 and 3.0. The company should integrate the surveillance and monitoring results with other data in risk assessments and performance measures, including proactive trend analyses. The company shall have documentation and records of its surveillance and monitoring programs.

References:
OPR-99 sections 36, 39, 47, 53(1) and 54(1)
CSA Z662-07 Clauses 10.2.2 and 10.14.1
CLC Part II 125(1)(c), 134.1(4)(d), 135(7)(k), 136(5)(g), 136(5)(j)
COSHR 4.5, 4.6, 5.10, 6.10(3), 10.18, 12.3, 12.14, 14.20, 14.21, 14.23, 15.6, 17.3, 17.9

Assessment:
As part of an O&M Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EHS MS.

Document review and staff interviews confirmed that the Operator conducts several activities for the purpose of measuring and monitoring the implementation of the EHS MS. Safety issues are discussed and tracked in: the development and review of daily and monthly progress reports; daily and weekly safety inspection reports; daily tool box meetings; weekly all staff meetings; weekly behavior based inspections; incident reporting and review; incident investigations; fire drills; and contractor inspection reports. Incidents without loss, as well as actual incidents, are reported in the Incident Learning and Prevention system (ILP) which is part of the EPASS system.

The Operator was able to demonstrate adequate development and implementation of the measuring and monitoring activities for its EHS MS.

Compliance Status: Compliant

4.2 Corrective and Preventive Actions

Expectations: The company shall have a process to investigate incidents or any non-compliances that may occur. The company shall have a process to mitigate any potential or actual issues arising from such incidents or non-compliances. Such mitigation may include appropriate timing and actions for addressing the issues that arise.

The company shall demonstrate that it has established a documented procedure to:

  • set criteria for non-compliance;
  • identify the occurrence of any non-compliances;
  • investigate the cause(s) of any non-compliances;
  • develop corrective and/or preventive actions; and
  • effectively implement the required corrective and/or preventive actions

The company should develop procedures to analyze incident data in order to identify deficiencies and opportunities for improvement in its management and protection programs and procedures.

References:
OPR-99 sections 6 and 52
CSA Z662 Clauses 10.2.2(g) and (h)
CLC Part II 125(1)(c), 125(1)(o), 125.1(f),134.1(4)(d), 135(7)(e), 135(7)(j), 136(5)(g)
COSHR sections 2.27, 7.3, 10.4, 10.5, 15.4, 19.1(1)

Assessment:
As part of an O&M Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EHS MS.

In the case of incident investigation, the Operator has a documented and comprehensive process in place which includes provisions for the reporting and investigation of incidents. In addition, the incident reporting and investigation process includes a review of significant safety related near misses as well as provisions for the review of contractors in incident investigations, when appropriate. The investigation process is designed to identify root causes and trends that will lead to corrective and preventive action. Staff analyzes incidents to detect patterns or trends to anticipate and prevent future incidents. The Operator uses the EPASS and Incident Without Loss (IWOL) System to track actions until they are completed and their effectiveness is verified. Safety lessons learned are documented and communicated to staff during the review and learns.

Document review confirmed that the Operator documents and reports incidents and accidents in accordance with its reporting policy. The Operator was able to demonstrate that it has adequate processes to ensure incidents are investigated and the appropriate measures are taken to correct or prevent further deficiencies in its EHS MS.

Compliance Status: Compliant

4.3 Records Management

Expectations: The company shall establish and implement procedures to ensure that the records supporting the management and protection programs are retained, accessible and maintained. The company shall, as a minimum, retain all records for the minimum lengths of time as required by the applicable legislation, regulation and standards incorporated by reference into the regulation.

References:
OPR-99 sections 47 and 56
CSA Z662-07 Clause 10.2.2(e)
CLC Part II 125(1)(g), 1.5, 2.23, 2.24, 2.27(7), 4.6
COSHR 5.17, 5.18, 6.10(7), 7.3(6), 8.18(7), 10.6, 10.15, 10.19(4), 11.12, 12.14, 14.23(4), 15.11, 16.13(2), 17.4(4), 17.8(2), 17.9(2), 17.10(2), 18.39, 18.40, 18.41, 18.42, 19.6(5), 19.8(2)

Assessment:
As part of an O&M Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EHS MS.

Operator’s safety program generates records including: daily and monthly progress reports; daily and weekly safety inspection reports; daily tool box meetings; weekly all staff meetings; weekly behavior based inspections; incident reporting and review; incident investigations; fire drills; and contractor inspection reports. The Operator uses EPASS for management and storage of all operational data and incidents with no time loss. Incidents are reported in the ILP System which is part of the EPASS system.

Board auditors confirmed that the Operator has a records retention process which includes types of safety related records to be retained, retention timeframe and disposal methods.

Compliance Status: Compliant

4.4 Internal Audit

Expectations: The company shall develop and implement a documented process to undertake audits of its management and protection programs and procedures. The audit process should identify and manage the training and competency requirements for staff carrying out the audits. These audits shall be conducted on a regular basis.

References:
OPR-99 sections 53 and 55
CSA Z662-07 Clauses 10.2.2(c) and (h)(iii)
COSHR 19.7(1)(2)

Assessment:
As part of an O&M Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EHS MS.

The Operator’s internal EHS program audits are conducted by EHS Audit Manger, Audit Services. The audit planning cycle is determined by a comprehensive risk assessment. The Board reviewed the 28 September 2009 EHS MS audit and protocols along with the audit response report which shows the progression of remedial action to address non-compliances identified in the audit. Remedial action is tracked in the EPASS system to ensure action items are closed-out. To ensure all legislated responsibilities are included, local subject matter experts are contracted to ensure appropriate legislation is included for the facilities being audited.

As previously noted in Element 2.2 of this report, the Operator could not demonstrate that it has a process to identify and integrate Canadian Occupational Health and Safety legislation into its Safety Program as required by NEB regulations and the CLC Part II.

It was verified through interviews and document review that the Operator has an internal audit program to assess its EHS MS against its regulatory requirements. However, the Board notes that the absence of an effective process to identify and integrate all of the legal operational safety requirements could lead to incomplete EHS audit protocols and inaccurate internal audit findings.

Compliance Status: Compliant with recommendation

5.0 MANAGEMENT REVIEW

5.1 Management Review

Expectations: Senior management should formally review the management and protection programs for continuing suitability, adequacy and effectiveness. The review should be based on appropriate documentation and records including the results of the surveillance, monitoring and audit programs. This review should be formal and documented and should occur on a regular basis. The management review should include a review of any decisions, actions and commitments which relate to the improvement of the programs and the company’s overall performance.

References:
OPR-99 section 55
CSA Z662-07 Clause 10.2.2(h)(iii)
COHSR sections 11.2(4), 12.10(1.2), 19.6(3), 19.7(1)-(2)

Assessment:
See Appendix VII for the assessment of this element.

Compliance Status: See Appendix VII for the assessment of this element.

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