ARCHIVED - National Energy Board Onshore Pipeline Regulations, 1999 (OPR-99) Final Audit Report for Integrity Management, Safety, Environmental Protection, Emergency Management, Crossings and Public Awareness Programs - Appendix VI - Public Awareness Program Audit Evaluation Table

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Appendix VI
Westcoast Energy Inc., carrying on business as
Spectra Energy Transmission (Westcoast)
Public Awareness Program Audit Evaluation Table

Table of Contents

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:Footnote 1

OPR-99 Sections 4, 47 and 48
CSA Z662-11 Clause 3.1.2(a)

Assessment:

Westcoast senior management participates in several committees that oversee the development and implementation of the policies that frame the Environment, Health and Safety (EHS) program. For the purposes of this audit, the Public Awareness (PA) Program is considered to be subsumed in the Safety Program. Westcoast management communicates the policy for EHS programs through an Operational Steering Committee. The EHS policy is signed off by Spectra Energy’s President and Chief Executive Officer.

The Policy was available at all sites and staff interviews confirmed that employees are aware of its existence. A review of the Policy from the 2012 purpose statement is as follows:
“To achieve our purpose we manage risk in everything we do, by continuously improving on:

  • Employee, contractor and vehicle safety;
  • Process safety;
  • Environmental Management ;
  • Reliability; and
  • Cost management.”

Although Westcoast was able to demonstrate that its Policy is signed off by senior management and communicated to employees; the audit found that “public safety” is not explicitly written into the purpose statement. Interviews confirmed that while staff members were familiar with the policy, they could not identify the link between the policy and public safety goals.

Due to the absence of public safety in the policy, the audit has determined that the current policy at Westcoast does not adequately create the required line of sight between the policy framework and support of the PA program. Therefore, the company policy does not demonstrate how Westcoast prioritizes and mitigates the risks regarding its interactions with and obligations to third parties and the public at large.

While it is understood that public safety is implied in the current policy, the NEB Act and associated regulations separate public safety as an explicit requirement.

Compliance Status: Non-Compliant

2.0 PLANNING

2.1 Hazards Identification, Risk Assessment and ControlFootnote 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), 37, 39, 40 and 41
CSA Z662-11 Clause 3.1.2 (f)

Assessment:

Westcoast’s PA Program is developed and revised to address the hazards to the system posed by third party activity. Under the direction of the Lands and Pipeline Safety Awareness director, Westcoast staff categorizes the risks by severity and likelihood for each region of the BC system. The PA Plan is then developed to address the hazards that have been identified.

According to Westcoast staff, they organize PA activities that correspond to the risks identified such as new urban developments or high risk activities in certain areas. The risk assessment also informs the outreach plan. For example, a special mail out of postcard reminders was organized to address the issue of deep tillage in the Fraser Valley. There are also new hazards identified by the PA group that are communicated to operational groups regarding potential class location issues within a new neighbourhood.

According to PA staff, there are a wide range of hazards that they could be exposed to during the performance of their duties. For staff who conduct resident visits, hazards they face include vicious dogs and hostility from third parties. Also, for staff working in Northern B.C., Westcoast has identified working in remote and isolated areas and wildlife such as bears as potential hazards. To address these hazards, Westcoast has developed policies and mandatory training requirements. For example, Westcoast requires that PA staff attend training in conflict resolution prior to working with third parties. All staff interviewed were aware of the policies that apply to their outreach activities, such as bear awareness and the work alone policies. If any safety-related incidents occur, they are tracked in the Incident Investigation Reporting Tracking (IIR) and noted in the Geographical Information System (GIS) for future reference.

Westcoast was able to demonstrate that its PA program has a procedure for hazard identification that includes risk assessment and controls both for the program development as well as staff protection.

Compliance Status: Compliant

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 and 6
CSA Z662-11 Clause 3.1.2(h)(i)
PCR Part II Sections 4 and 5

Assessment:

Westcoast monitors legal requirements through a subscription to Temple Gate Information Services Inc. and Cyber Regs. Also, Westcoast has staff members that participate in professional organizations such as CEPA and the Canadian Common Ground Alliance. Westcoast’s Regulatory Affairs group communicates regulatory changes via email to all group leads. It is then up to the recipients on the distribution list to identify any changes that are relevant to their respective operational processes. For example, according to staff, it was the Regulatory Affairs office that ensured that Westcoast complied with the Exemption Order Respecting Crossings by Agricultural Vehicles or Mobile Equipment (NEB M0-21-2010). Document review also demonstrated that regulatory references are identified in some Standard Operating Procedures (SOPs).

While the company was able to demonstrate that communication of regulatory requirements is occurring, and that personnel are incorporating new requirements into the procedures, Westcoast did not demonstrate that there is an inventory of legal requirements or a formal process to verify whether the PA Program is meeting all of its legal requirements.

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 Sections 47 and 48
CSA Z662-11 Clause 3.1.2(h)(ii)

Assessment:

Westcoast sets goals at various levels of the organization. At the corporate level, set goals often include issues related to safety and operations. For example, one of this year’s corporate goals was for 100% of staff to complete the core safety training by 31 October 2012. Staff goals and targets are developed, in part, to reflect the corporate ones such as completing safety training. Staff goals and targets are established in staff development plans and then managed and tracked through performance management and tied to the organization-wide Short-term Incentive Pay (STIP) program.

Within the Lands and Awareness group, goals are established for the Continuing Education (Emergency Response) and PA Program on a three year cycle. To evaluate whether the program has met its targets, PA staff track statistics related to their outreach activities such as number of stakeholder visits conducted, number of trade shows attended and number of attendees at its contractor awareness events. They also include statistics that measure the impact of the PA Program such as reports regarding the number of one-calls received, the number of unauthorized activities reported and the feedback from outreach events. This qualitative and quantitative data is analyzed and incorporated into the PA Program in order to identify new potential audiences or activities. Document review confirmed that goals and targets are established annually relating to the PA Program staff and activity development.

Westcoast was able to demonstrate that there is a process for establishing goals, targets and objectives for its PA Program, and that related issues are monitored and measured, and used to form the basis of the plan going forward.

Compliance Status: Compliant

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 Sections 40, 47 and 48
CSA Z662-11 Clause 3.1.2(b)

Assessment:

The Westcoast PA Program is managed under the Director of Lands and Pipeline Safety Awareness out of Vancouver. Reporting to the Director are the Team Leaders for PA, Crossing Administration and Damage Prevention and the Manager of Lands, Field Operations. The Team Leader for PA has one full-time report in Fort St. John and five contract employees through HMA Land Services in each of the Central, Southern and Northern areas of B.C. The Team Leader chairs a weekly conference call with the group and conducts reviews annually to discuss performance, goals and targets. The Team Leader reviews the workload with the Director during quarterly reporting.

According to the Continuing Education and Public Awareness Program 2012-2014 document, each member of the team is assigned a certain number of visits for awareness and Emergency Planning Zone (EPZ) resident education on a three-year rotation. There are approximately 2800 right of way residents and 6400 EPZ residents that require visits and awareness information. Each visit is attempted three times and, if they are unable to speak in person, they leave the package which contains a change of contact/household information form and a return envelope. If changes to contact information are required, the PA staff and contractors enter the information in GIS. In order to determine whether there are adequate resources, the Team Leader meets quarterly with the Director to discuss the planned activities and program goals and current staff workload.

Westcoast was able to demonstrate that it has a functioning structure to maintain the program as designed. Staff indicated that given the size of the area that each staff/contractor is responsible for, and the ongoing increase in activity the structure will be reviewed in the next year to ensure that Westcoast can maintain an effective PA Program as required in the PCR.

Compliance Status: Compliant

3.2 Management of Change

Expectations:

Expectations: The 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 Z662-11 Clause 3.1.2(g)

Assessment:

Management of Change (MOC) related to Lands and Crossings is managed out of Vancouver, British Columbia and MOC for asset changes is managed at local facilities. Its current MOC program has scoped in PA as a group that needs to be notified and evaluated for potential impacts when there are changes in the information technology. The MOC Descriptions of Affected Applications, Systems, Documentation and Processes describes the circumstances for involving the PA Program in the MOC process. Review of the documentation provided indicates that the triggers for the MOC process and the PA Program mainly involve the GIS system. While it is understood that changes to the GIS database should be managed, it is not clear what other types of changes at Westcoast would trigger the MOC process and when the PA Program would be notified and considered in that change.

Interviews confirmed that Westcoast is in the process of developing and implementing an Operations Management System (OMS). Westcoast indicated that it intends to incorporate the MOC process in the new OMS.

Although there are aspects of a functioning asset-based MOC process, and improvements are scheduled for implementation, at the time of the audit, Westcoast failed to demonstrate that it has implemented a comprehensive MOC process that includes the appropriate triggers to include the PA Program.

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 requirement.

References:

OPR-99 Sections 28, 29, 30(b), 46, 47, 48 and 56
CSA Z662-11 Clause 3.1.2(c)(iii)

Assessment:

Westcoast manages employee required training such as safety training in the Learning Management System (LMS). Administrative staff in the Vancouver office manages training records for the Lands and Pipeline Safety teams. The system attaches expiration dates on required courses for Westcoast staff and sends out email alerts three months before the training has expired. Interviews confirmed that employees in the field offices were aware of LMS and the online courses available in that database.

The PA Team Leader also recommends training to her staff as part of professional development. Due to their role in the Emergency Program and continuing education program, the PA staff attends training for the Incident Command system as well as courses to improve their communication and conflict resolution skills. The same awareness and emergency continuing education training is provided, tracked, and managed for contract PA staff. Contract staff is also subject to regular performance reviews by the PA Team Leader.

Westcoast was able to demonstrate that it has a process to identify, track and maintain records on employee training. As well, Westcoast demonstrated that staff and contractors involved in the PA and Continuing Education Program are trained and evaluated on a regular basis.

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;
  • to communicate the program’s roles and responsibilities to interested persons.

References:

OPR-99 Sections 18, 28 and 29
CSA Z662-11 Clause 3.1.2(d)
PCR Part II Sections 4 and 5

Assessment:

The Team Leader of PA provides a script to staff and contractors that conduct the visits with third parties to ensure the consistency of information to all stakeholders. Document review of the script, as well as the standard awareness presentations, confirmed that safety messages are consistent. Westcoast’s outreach plan includes open houses, as well as presentations to various stakeholder groups where they present safety messages related to the Westcoast system and upcoming projects. Also, Westcoast works with BC Common Ground Alliance and BC One-Call to organize contractor safety breakfasts, Digsafe BC! Workshops and other related trade shows to discuss general safety practices and regulatory requirements for working around federally-regulated pipelines. These safety associations also place ads with safety messages in trade journals and community newsletters. Special mail outs are organized to address particular issues, such as deep tillage in the Fraser Valley. The external website also contains readily available safety and contact information.

Internal communication at Westcoast occurs formally at bi-weekly PA/Emergency Management meetings, and at monthly meetings with Community Coordinators to discuss the Aboriginal Engagement Program. The team also receives reports from integrity and damage prevention regarding unauthorized activity reports and trends.

Westcoast was able to demonstrate that it has established a PA Program and that it measures the effectiveness of this program on a regular basis. Although communication is occurring within the PA Program, and there are triggers in place from the program to communicate with external stakeholders, Westcoast failed to demonstrate that there is a formal communication plan that includes the PA program in order to ensure that relevant information is communicated in a timely way throughout the organization.

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 Section 27
CSA-Z662 11 Clause 3.1.2(e)(f)
PCR Part II Sections 10 and 11

Assessment:

Westcoast employees store and use procedures and templates that are saved on its intranet site called “the Source.” The Lands and Pipeline Safety Group has created a page to post all of the forms, policies and related links for their group. The PA group also has a site on the Source for its information. The site is maintained at the Vancouver office. If changes or enhancements are made to any of the procedures or forms, the Crossing Administration and Damage Prevention Lands Group upload the new documents and announce the new versions by email. Interviews confirmed that field staff was aware of the requirement to use documents from the Source to ensure that they were using the most recent versions.

The Continuing Education and PA Plan, which includes the scripts for resident visits, serves as a guideline for the program. This document is controlled in the Vancouver office and maintained on the Source. Presentations for the various stakeholder groups are kept on the shared G drive and available to all Westcoast staff.

Westcoast was able to demonstrate that it has implemented a document management process to maintain and communicate the policies and procedures related to its PA Program.

Compliance Status: Compliant

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 21, 27 to 49
CSA Z662-11 Clause 3.1.2(c)
PCR Part II Sections 4 and 5

Assessment:

In order to be proactive, Westcoast develops a three-year outreach plan which includes right of way residents, those dwellings that are adjacent to the right of way as well as residents of the Emergency Planning Zone (EPZ). The goal of the plan is to conduct in-person visits for each of the right of way and EPZ residents every three years. Activities associated with this outreach program include open houses and scheduled presentations to various stakeholder groups where they present safety messages related to the Westcoast system and projects. In order to reach a wider audience, Westcoast places ads with safety messages in trade journals and community newsletters. Also, Westcoast works with BC Common Ground Alliance and BC One-Call to organize contractor safety breakfasts, Digsafe BC! Workshops and other related trade shows to discuss general safety practices and regulatory requirements for working around federally-regulated pipelines.

Westcoast was able to demonstrate that it has a PA Program to address the risks and hazards associated with third-party in accordance with the legal requirements.

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 consequence and/or impacts of these events. The procedures must be periodically tested and reviewed and revised where appropriate (for example, after emergency events).

References:

OPR-99 Sections 32, 52
CSA Z662-11 Clause 10.5.2

Assessment:

Although the Westcoast Emergency Management Program is evaluated in more detail in Appendix IV of this report, there is significant overlap with the PA Program.

Westcoast has combined the continuing education of first responders and EPZ residents from the emergency preparedness programs with the provision of safety information of the PA Program. The same group conducts the outreach to residents and other stakeholders with a combined message of working safely around pipelines as well as what to expect in the event of an emergency. In the event of an emergency, the PA group would assist in the communication with stakeholders including residents and first responders, as well as community members along its system. Also this group supports the emergency management process by obtaining and confirming resident information for the GIS database. During their regular visits, staff members confirm the number of occupants, and whether any household has special evacuation requirements.

Westcoast was able to demonstrate that its PA Program is integrated with the Continuing Education Program to meet the requirements of OPR-99.

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 and 39
CSA Z662-11 Clause 10.6.1
PCR Part II Sections 4, 5, 10 and 14(1)

Assessment:

According to staff, in order to measure and monitor the effectiveness of its PA Program, Westcoast hires a third party survey company to conduct telephone surveys with stakeholders every three years. Responses to the survey are analyzed and results are used for planning activities as well as enhancements to the program where required.

A review of the survey confirmed that stakeholders are asked about their comprehension of the safety messages as well as their level of satisfaction with the Westcoast PA Program. Also, Westcoast obtains feedback from third parties during the stakeholder visits, following the safety presentations and the safety events in which it participates. The Public Awareness Team uses the feedback to review its program and identify opportunities to improve the PA program.

Compliance Status: Compliant

4.2 Corrective and Preventive Actions

Expectations:

The company shall have a process to investigate incidents or any non-compliance 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 preventative actions; and
  • effectively implement the required corrective and/or preventative 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 Z662-11Clause 3.1.2(h)(i)
PCR Part II Section 13

Assessment:

All contraventions of the PCR are deemed unauthorized activities. While the unauthorized activities are addressed and managed through the Damage Prevention and Lands Teams, the PA Team uses the reports and trends to inform the PA Program on an ongoing basis in order to identify trends or particular areas that should be targeted for awareness For instance, when deep tilling in the Fraser Valley was identified as a potential safety issue, the PA team created and distributed safety awareness material specifically for the farmers in that area. According to staff, the PA Team also conducts “on-demand” awareness presentations or workshops when a party has been identified for awareness and safety information based on an unauthorized activity report.

Westcoast was able to demonstrate that the PA Program is integrated into its response to third party unauthorized activities.

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 41, 51, 52 and 56
CSA Z662-11 Clause 3.1.2(e)
PCR Part II Sections 10(c), 11(1) and 16

Assessment:

Westcoast maintains several databases for the records generated by its business. For PA Program related files, most records generated by work done are kept in the PA application on the GIS database. Records, such as contact information for residents along the right of way or adjacent to the right of way, as well as EPZ residents are uploaded to GIS and thereby linked to the map. Other information such as number of residents, special needs, pets on the premises, etc. can also be entered into GIS and searched when required. The information is confirmed every three years during the landowner visits. Westcoast notifies tenants as well as landowners and contact information is also entered into the GIS.

Westcoast staff members at all locations have access to all of the layers of information. It is used to obtain a current snapshot as well as a history of a particular location. The system has several layers of data entered so it is useful for many teams. A review of the database entries showed that Westcoast enters all related filings, correspondence, unauthorized activities, resident complaints, etc. by using the GIS coordinates. The result is that staff can obtain a history of activity as well as resident information in one database for awareness and emergency purposes.

Westcoast was able to demonstrate that it has processes in place to manage the records generated by and for the PA Program.

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 Section 53
CSA Z662-11 Clause 3.1.2(h)(iii)

Assessment:

Senior management of Spectra Audit Services is located in Houston, Texas. However, an audit manager and several staff are located in Calgary, Alberta. Calgary-based audit staff perform most of the Westcoast internal audits, sometimes with participation by Houston-based audit staff. These audits occur on a regular basis and vary in size and scope. The team audits Westcoast’s performance against Spectra’s established program requirements. Once the audits are complete, all non-compliant findings are tracked through a database until resolved and reported to upper management.

Although Westcoast was able to demonstrate that it assesses the effectiveness of its PA Program on a regular basis using surveys and trend analysis, it was not able to demonstrate that the PA program has been scoped into any internal operational audits or that the existing audit process incorporates an evaluation of the program’s compliance to the regulatory requirements.

Also it did not demonstrate that the requirements of the PCR are included in its audit protocols for audits regarding safety of the public.

Compliance Status: Non-Compliant

5.0 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 53
CSA Z662-11 Clause 3.1.2(a)
PCR Part II Sections 4 and 5

Assessment:

According to staff, the PA, Lands and Damage Prevention teams report their respective program results to the Director of Lands and Pipeline Safety. These reports form the basis for the programs going forward and are also discussed during performance reviews.

Interviews with senior management confirmed that reports of unauthorized activity trends are discussed at a senior management level. These reports are synthesized into management’s overall safety and performance reporting. Management from head office also conducts mandatory safety stand down meetings which often address topics related to third-party damage prevention.

While the Board acknowledges that there is communication occurring, Westcoast was unable to demonstrate that it has established the required processes that contribute to an adequate management review. As noted in element 2.2 of this report, Westcoast does not have a formal process of confirming that there is a current and complete inventory of legal requirements guiding the development and implementation of its PA program. Also, Westcoast’s internal audit process does not include an evaluation of compliance to the PCR which outline the requirements for addressing third party activities. Without this confirmation of compliance, senior management cannot verify that the PA program is operating in compliance with all of the requirements. As well, Westcoast’s policy and purpose statement does not explicitly include public safety, and so there is no clear line of sight from Westcoast’s policy to the PA Program. Therefore the Board is not satisfied that there are sufficient processes in place by senior management to allow for a formal and documented management review to ensure ongoing suitability of the PA Program.

While Westcoast was able to demonstrate that some communication was occurring regarding the PA program, it could not demonstrate that Senior management formally evaluates the performance of the PA program. Also, the audit determined that the internal audit process does not include an evaluation of Westcoast’s compliance to the requirements of the PCR.

Compliance Status: Non-Compliant

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