ARCHIVED - National Energy Board Onshore Pipeline Regulations (OPR) – Final Audit Report of the Alliance Pipeline Ltd. Third Party Crossings Program – Appendix I – Third Party Crossings Program Audit Evaluation Table

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Appendix IFootnote i

Third Party Crossings Program Audit Evaluation Table

Table of Contents

1.0 POLICY AND COMMITMENT

1.1 Leadership Accountability

Expectations:

The company shall have an accountable officer appointed who has the appropriate authority over the company’s human and financial resources required to establish, implement and maintain its management system and protection programs, and to ensure that the company meets its obligations for safety, security and protection of the environment. The company shall have notified the Board of the identity of the accountable officer within 30 days of the appointment and ensure that the accountable officer submits a signed statement to the Board accepting the responsibilities of their position.

Assessment:

Accountable Officer

The Board requires the company to appoint an accountable officer. The accountable officer must be given appropriate authority over the company’s human and financial resources for ensuring that the company meets its obligations for safety, security and protection of the environment.

On 10 May 2013, Alliance submitted written notice to the Board indicating that its President and Chief Executive Officer, Terrance Kutryk, had been appointed as the accountable officer for Alliance Pipeline Ltd. The audit team verified that there have been no changes in the accountable officer for Alliance Pipeline Ltd. at the time of the audit. In its submission, Alliance confirmed that its accountable officer has the authority over the human and financial resources required to meet the Board’s substantive expectations.

Summary

Based on the Board’s evaluation of Alliance’s Third Party Crossings (Crossings) program against the requirements, the Board has determined that Alliance is Compliant with this sub-element.

Compliance Status: Compliant

1.2 Policy and Commitment Statements

Expectations:

The company shall have documented policies and goals intended to ensure activities are conducted in a manner that ensures the safety and security of the public, workers, the pipeline, and protection of property and the environment. The company shall base its management system and protection programs on those policies and goals. The company shall include goals for the prevention of ruptures, liquids and gas releases, fatalities and injuries and for the response to incidents and emergency situations.

The company shall have a policy for the internal reporting of hazards, potential hazards, incidents and near-misses that includes the conditions under which a person who makes a report will be granted immunity from disciplinary action.

The company’s accountable officer shall prepare a policy statement that sets out the company’s commitment to these policies and goals and shall communicate that statement to the company’s employees.

References:

PCR Part II section 4; OPR sections 6.1, 6.3, 40, 47, 48

Assessment:

The Board expects companies to have documented policies and goals intended to ensure activities are conducted in a manner that ensures the safety and security of the public, workers, the pipeline, and protection of property and the environment. The Board also expects companies to have a policy for the internal reporting of hazards, potential hazards, incidents and near-misses that includes the conditions under which a person who makes a report will be granted immunity from disciplinary action.

Policies

Alliance has established corporate policies within its Operational Risk Management System (ORMS). These policies are approved by the Alliance President and Chief Executive Officer (CEO). The ORMS outlines the company’s vision and overarching corporate goal “No safety, pipeline, or environmental incidents” and this is demonstrated by referring to supporting corporate policies such as:

  • Code of Business Conduct;
  • Environment Policy;
  • Health and Safety Policy; and
  • Security Policy.

The ORMS Policy document also defines the accountability and responsibility with the CEO responsibilities and all employees, contractors and consultants’ responsibilities described.

The Board has verified that Alliance’s Accountable Officer has prepared a policy statement that sets out Alliance’s commitment to these policies as outlined in the ORMS Policy. The policy statement includes commitments to the protection of people, property, environment and to the use of ORMS. Commitments are made to employee-partners to encourage the reporting of all incidents, hazards, near misses and risks and protecting employee-partners and contractors who report in good faith from any form of retaliation for reporting. The policy is available to all personnel at Alliance through the company intranet. The Board verified through record review and interviews with Alliance representatives that Alliance communicated the ORMS Policy to its employee-partners.

While the ORMS Policy substantially meets the OPR requirements, it does not explicitly refer to the reporting of ‘potential hazards’ as required by the regulations. Review of the supplied information also identified that the Alliance policies did not explicitly identify the conditions under which a person who makes such a report will be granted immunity as part of the reporting policy. The Board notes that the policies are required to be explicit with respect to reporting and what to report in order to, not only encourage reporting but also to clearly identify what to report. Alliance’s statements would require interpretation prior to reporting thus potentially slowing down hazard management and mitigation.

During interviews, Alliance representatives confirmed that, given its role in maintaining public safety, the Crossing program aligns with the Health and Safety Policy and that this policy, in addition to others, have been communicated to all Alliance Crossings personnel.

Summary

The Board found that Alliance has developed policies and policy statements to meet the requirement of OPR, section 6.3(1) for its programs required by OPR section 55. As the Crossings program is subsumed within the Safety Management program, the Board has determined that Alliance has aligned its Crossing program with these policies.

The Board also found the following areas of non-compliance in the Policy and Commitment Statements sub-element:

  • Alliance did not demonstrate that it has a policy that explicitly describes internal reporting of potential hazards as required by OPR, section 6.3(1)(a); and
  • Alliance did not demonstrate that its policy includes the conditions under which a person who reports a hazard, potential hazard, incident or near-miss will be granted immunity from disciplinary action as required by OPR, section 6.3(1)(a);

Based on the Board’s evaluation of Alliance’s Crossings program against the requirements, the Board has determined that Alliance is Non-Compliant with this sub-element. Alliance will have to develop corrective actions to address the described deficiencies.

Compliance Status: Non-Compliant

2.0 PLANNING

2.1 Hazard Identification, Risk Assessment and ControlFootnote 1

Expectations:

The company shall have an established, implemented and effective process for identifying and analyzing all hazards and potential hazards. The company shall establish and maintain an inventory of hazards and potential hazards. The company shall have an established, implemented and effective process for evaluating the risks associated with these hazards, including the risks related to normal and abnormal operating conditions. As part of its formal risk assessment, a company shall keep records to demonstrate the implementation of the hazard identification and risk assessment processes.

The company shall have an established, implemented and effective process for the internal reporting of hazards, potential hazards, incidents and near-misses, and for taking corrective and preventive actions, including the steps to manage imminent hazards. The company shall have and maintain a data management system for monitoring and analyzing the trends in hazards, incidents, and near-misses.

The company shall have an established, implemented and effective process for developing and implementing controls to prevent, manage and mitigate the identified hazards and risks. The company shall communicate those controls to anyone exposed to the risks.

References:

Crossings: PCR Part II section 4, OPR sections 6.1, 6.5(1)(c)(d)(e)(f)(r)(s), 40, 47, 48

Assessment:

The scope of this audit includes the review of the process for addressing third party requests for permission to cross, conduct excavation or construction activities in proximity to NEB regulated Alliance facilities. These requests from third parties including landowners, land users, municipalities and other utilities are managed by the processes and staff of Alliance’s Lands, Right of Way and Corridor Management (LRCM) Department.

The Board expects companies to have an established, implemented and effective process for identifying and analyzing all hazards and potential hazards. The company shall also establish and maintain an inventory of hazards and potential hazards.

Identifying Hazards and Potential Hazards

The Board verified that requests from third parties are managed by the processes and staff of the LRCM Department. Alliance’s Crossing program is managed within its LRCM Program and is supported by the Integrity, Public Awareness and Damage Prevention Programs.

For the Crossings program, hazards are identified during the review of the requests for permission to cross upon receipt and managed according to the type of project being proposed. In order to identify the hazards and potential hazards of proposed third party activity in proximity to its pipeline, Alliance has an established Threat Hazard Assessment and Review Practice. This framework is applied to ensure that threats / hazards are identified and addressed in a manner consistent with Alliance’s policies and regulatory requirements. The practice includes a Crossings activity flow chart that describes the hazard evaluation and categorizes each request for permission based on the type of project being proposed. The more complex the proposed project, the more review and assessment may be required from other departments such as Integrity. The majority of the approximately 600 requests for permission to cross are submitted through the One-Call systems. Once the requests are found to be complete, they are classified at the Head Office based on complexity as per the Field Representative Crossing Activity Flowchart and managed through the Digtrack system.

The Board verified that the process to review requests for permission to cross includes a hazard assessment. The Board also verified that the practice has been developed, approved, communicated and trained upon with the appropriate Crossings staff for the administrative as well as the field activities.

Alliance has also implemented field-based processes to identify hazards and potential hazards that could impact its Crossings program through periodic monitoring of the conditions and activities along its right of way. Depth of cover monitoring is performed by operations field staff and tracked in Alliance’s internal database. Rights-of-way (ROW) surveillance through aerial patrols is another method used to identify areas of potential unauthorized third party activity. As well, each ROW patrol identifies and track potential hazards such as new developments along the ROW. These potential developments are monitored as points of interest (POIs) and are documented and tracked in a data management system.

Analysis of Hazards and Potential Hazards

At the time of the audit, Alliance demonstrated that the analysis of hazards and potential hazards occurs throughout the request for permission review process. Accordingly, Alliance has developed its process to reflect the various types of crossing applications it receives and the legal requirements governing those applications. Review of Alliance’s Crossings program and associated procedures found that these documents outline the process to manage the various types of third party excavation and construction applications. Review has further determined that these processes include the requirements for the identification and analysis of hazards and potential hazards of requests for permission to excavate using power operated equipment, explosives or construct facilities on, along, under or across Alliance’s facilities. For vehicle crossings, Alliance indicated that it analyzes the hazards related to the surface loading by using the stress calculator developed by the Canadian Energy Pipelines Association (CEPA).

When Alliance receives a request for permission from a third party, the proposed project is assessed based on parameters outlined in the standard and complex projects are reviewed by the Integrity Group for the assessment and identification of appropriate safety measures. Once the required analysis is completed, the application is returned to the Crossing group for processing. This group ensures that the safety measures and instructions are included into the Foreign Crossing Notice package for communication to the third party. Once the agreement has been signed off, a copy of the crossing agreement is sent to the appropriate area office for its files.

Controls

Through interviews and document review, the audit confirmed that there are controls for these hazards reflected in Crossing and Damage Prevention programs initiatives and outcomes. Further, it was noted that the hazards managed within the Crossings program are considered within the risk assessment practices established in other Alliance technical programs required by the Board such as Alliance’s Integrity Management, Safety Management and Emergency Management programs. Safety and Emergency Management programs are the subject of concurrent audits conducted by the Board.

Document review confirmed that the Crossing program in conjunction with the Damage Prevention program uses the LRCM Threat / Hazard Review Practice and Operations Work Order Management Field Guide to identify the circumstances when safety measures such as engineering assessments, onsite representation, pipe locates or post-construction inspections are specifically required for a given request. These program documents also outline the decision-making process for each set of potential circumstances. Once the hazards associated with the request for permission have been assessed, the LRCM staff determines the necessary safety mitigation steps and processes the requests accordingly.

Third parties who apply to excavate or construct near a pipeline or cross a ROW with heavy machinery are provided with safety information within the crossing agreements obtained from the LRCM team. Also, Alliance’s process dictates when a field representative is required to monitor the project. In addition, Alliance uses a vehicle load crossing stress calculation to evaluate whether heavy machinery crossings can be allowed and what, if any, provisions such as temporary crossings are required. Copies of the approved requests for permission and associated documents are made available to Alliance staff in the region of the project.

The Board identified that Alliance has been managing its hazard identification requirements by undertaking several activities along its ROW related to third party activity. These activities aid in the identification and monitoring of new potential hazards from external sources. Examples of these activities include: annual aerial ROW class location surveys, tracking of potential hazards as “points of interest” in a data management system, annual patrol, monthly aerial patrols in each region. The Board verified that Alliance uses various methods to identify hazards and potential hazards for the Crossings program along its ROW. Alliance demonstrated that there are processes in place to identify and report hazards and potential hazards internally through its internal data management system.

Summary

The Board found that Alliance has processes for identifying hazards that meet the Board’s requirements of established and implemented for the Crossings and Damage Prevention Programs.

The Board found that Alliance demonstrated that it has established and implemented a Crossing program that incorporates a process for the identification of hazards as well as a process to evaluate the risks related to requests for permission from third parties. The Board also found that Alliance has an established process to introduce and communicate the required controls related to the identified hazards.

Based on the Board’s evaluation of Alliances Crossings program against the requirements, the Board has not found any issues of Non-Compliance. The Board has determined that Alliance is Compliant with this sub-element.

Compliance Status: Compliant

2.2 Legal Requirements

Expectations:

The company shall have an established, implemented and effective process for identifying and monitoring compliance with all legal requirements that are applicable to the company in matters of safety, security and protection of the environment. The company shall have and maintain a list of those legal requirements. The company shall have a documented process to identify and resolve non-compliances as they relate to legal requirements, which includes updating the management and protection programs as required.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(g)(h)(i), 40, 47, 48

Assessment:

The Board requires that companies have a process for identifying and monitoring compliance with all legal requirements and to maintain a list of these requirements.

Identifying and Monitoring Compliance

As part of its demonstration, Alliance pointed the Board to their centralized compliance management system (CCMS) and the systems supporting documentation as their established and implemented documented process for identifying legal requirements. Upon review, the Board determined that these documents do not include the steps to how the legal requirements were identified but focused on how to use the CCMS. As a result, Alliance was unable to demonstrate that it has established and implemented a documented process to identify all legal requirements applicable to the company. The Board notes that while a management system process deficiency currently exists, the Board did confirm through interviews with Alliance representatives that Alliance, with the support of a third party provider and internal subject matter expertise, did identify legal requirements that, in the opinion of Alliance, are applicable to the company. Please refer to the Legal List below for additional details.

Similar to above, Alliance pointed to its CCMS documentation in order to demonstrate that it has established and implemented a process for monitoring compliance with its applicable legal requirements. Upon review, the Board found that this documentation is focused on monitoring changes to legal requirements. While monitoring changes to legal requirements is one aspect of monitoring compliance and is required to be accounted for in the OPR’s management of change process, the Board notes that this is a reactive approach and does not proactively ensure that Alliance is in compliance with its current legal requirements (see Sub-element 4.1 Inspection, Measuring and Monitoring for additional details). The Board notes that while a process deficiency currently exists, the Board did confirm through interviews with Alliance representatives and documentation review that Alliance is monitoring compliance with applicable legal requirements through several Crossings program level practices.

Legal List

As noted earlier, Alliance has developed a centralized electronic library, CCMS, in order to the meet the Board’s requirements to maintain a legal list.

During the audit, Alliance provided several demonstrations of this system and how it will be utilized to ensure Alliance remains in compliance with applicable legal requirements through various processes, procedures and practices. The Board verified that Alliance has established and maintained a legal list that includes all applicable federal and provincial requirements for the various protection programs included in this audit. However, Alliance’s legal list does not include referenced standards, with the most notable omission being the Canadian Standards Association (CSA) library of standards. During interviews, Alliance indicated that it is barred from incorporating any CSA standards content into its legal list due to CSA copyright restrictions. While the Board agrees that copyright restrictions may exist, it should not limit Alliance from listing the clause numbers of the specific provisions and not the actual text of the provisions. This alternative was discussed with Alliance during the audit with Alliance indicating that this would be unworkable for the following reasons:

Communicating Legal Requirements

As noted earlier, Alliance has developed a centralized electronic library, CCMS, in order to the meet the Board’s requirements to maintain a legal list.

During the audit, Alliance provided several demonstrations of this system and how it will be utilized to ensure Alliance remains in compliance with applicable legal requirements through various processes, procedures and practices. The Board verified that Alliance has established and maintained a legal list that includes all applicable federal and provincial requirements for the various protection programs included in this audit. However, Alliance’s legal list does not include referenced standards, with the most notable omission being the Canadian Standards Association (CSA) library of standards. During interviews, Alliance indicated that it is barred from incorporating any CSA standards content into its legal list due to CSA copyright restrictions. While the Board agrees that copyright restrictions may exist, it should not limit Alliance from listing the clause numbers of the specific provisions and not the actual text of the provisions. This alternative was discussed with Alliance during the audit with Alliance indicating that this would be unworkable for the following reasons:

  • Reliability and Usage Considerations – Since the purpose is ultimately to ensure compliance, the legal list must be easy to use and maintain. And above all else, it must be reliable. In order to achieve these ends, Alliance is of the view that the actual text of the requirements must be set out explicitly. If users are required to continually cross-reference the source document against the clause numbers, errors will inevitably result, rendering the list unreliable and possibly even creating a greater risk of non-compliance.
  • Additional Challenges of Cross-Referencing – The need to continually cross-reference would make auditing against the requirements much more difficult and also raise challenges in terms of keeping the list current.
  • Administrative Burden – Alliance secured the services of a third party provider to extract the legal requirements from the source document and enter them into their system on Alliance’s behalf. In this case, copyright restrictions bar Alliance from disclosing CSA standards to their third party provider. Alliance would therefore have to bear the administrative burden of extracting the clause numbers that are associated with the legal requirements.

Alliance also indicated that “it does not see any practical merit in replicating the voluminous content of consensus standards in a legal list” as company personnel have access to the standards and are fully cognizant on how these standards apply to the respective areas.

The Board agrees that the copyright restrictions may present a barrier from a development and maintenance perspective. However, it’s the Board opinion that having these applicable clauses listed, albeit in an abbreviation aspect, would achieve a higher probability of compliance versus relying solely on the company’s subject matter expertise. As a result, the Board has determined that Alliance has not demonstrated a legal list that the meets the requirements of the Board.

Communicating Legal Requirements

The Board verified that Alliance was communicating legal requirements to third parties within the Crossing Agreements, its website and its Public Awareness program.

Summary

The Board found that Alliance demonstrated that it was tracking, listing and communicating some of its legal requirements.

The Board found that Alliance had developed and implemented practices to communicate the legal requirements internally and with third parties. Alliance did demonstrate that it had effective methods for communicating new or revised legal requirements to third-parties through its Public Awareness program.

The Board also found that Alliance’s methods to monitor its legal requirements and compliance to them did not meet the Board’s requirements.

The Board found that Alliance’s legal list was not kept at the level of specificity required to enable the company to ensure and monitor its compliance with the legal requirements.

Based on the Board’s evaluation of Alliance’s Crossings program against the requirements, the Board has determined that Alliance is Non-Compliant with this sub-element. Alliance will have to develop corrective actions to address the described deficiencies.

Compliance Status: Non-Compliant

2.3 Goals, Objectives and Targets

Expectations:

The company shall have an established, implemented and effective process for developing and setting goals, objectives and specific targets relevant to the risks and hazards associated with the company’s facilities and activities (i.e., construction, operation and maintenance). The company’s process for setting objectives and specific targets shall ensure that the objectives and targets are those required to achieve its goals, and shall ensure that the objectives and targets are reviewed annually.

The company shall include goals for the prevention of ruptures, liquid and gas releases, fatalities and injuries, and for the response to incidents and emergency situations. The company’s goals shall be communicated to employees.

The company shall develop performance measures for assessing the company’s success in achieving its goals, objectives, and targets. The company shall annually review its performance in achieving its goals, objectives and targets and the performance of its management system. The company shall document the annual review of its performance, including the actions taken during the year to correct any deficiencies identified in its quality assurance program, in an annual report, signed by the accountable officer.

References:

PCR Part II section 4, OPR sections 6.1, 6.3, 6.5(1)(a)(b), 6.6, 40, 47, 48

Assessment:

The Board expects that companies have an established, implemented and effective process for developing and setting goals, objectives and specific targets relevant to the risks and hazards associated with its facilities and activities (i.e., construction, operation and maintenance). Further, the company’s process for setting objectives and specific targets shall ensure that the objectives and targets are those required to achieve its goals, and shall ensure that the objectives and targets are reviewed annually.

Goals, Objectives and Targets

The Board requires the company to document its policies and goals for ensuring its activities are conducted in a manner that ensures the safety and security of the public, workers and pipeline, and the protection of property and the environment. Through interviews and documentation review, Alliance demonstrated its senior leadership team has developed goals to meet the obligations referred to above. These goals are reviewed and reported upon during the quarterly and annual management review meetings.

In addition, the OPR specifically requires goals for the following:

  • Prevention of ruptures;
  • Prevention of liquid and gas releases;
  • Prevention of fatalities and injuries; and
  • Response to incidents and emergency situations.

While Alliance has established documented goals for the prevention of ruptures, fatalities and injuries, its documented goals for the prevention of liquid and gas releases is limited to its pipeline ROW and does not include its aboveground facilities. As for goals for the response to incidents and emergency situations, Alliance did not develop a specific goal other than to track whether they had to respond to an incident or emergency situations. The Board expects that goals for these types of events should include, but not limited to, incident response times.

At the time of the audit, the Board verified that the process for developing objectives and targets was being completed at the Crossing program level. As demonstrated in its annual Accountable Officer Report, Alliance has established strategic management goals, objectives, performance measures and targets that are reviewed annually. Specifically for the Crossings program, one of the objectives related to the goal of zero leaks or ruptures is that “excavators are informed of their obligations with respect to work within the Alliance easement or the pipeline Safety Zone”.

In order to evaluate performance of the Crossings program, Alliance has developed goals based on operational service standards. Alliance Head Office tracks the number of crossings permissions granted that are managed by its Crossings Group. For example, the LRCM group tracks the number of requests for permission granted that met the internal service standards.

At the staff level, Alliance ties personal performance of its employee partners to program goals through accountability agreements and the short term incentive program. These agreements show the line of site from corporate to team to each individual’s goals.

Summary

The Board found that Alliance has developed and measures targets related to meeting operational service standards for its Crossing program.

The Board also found that Alliance has defined an objective related to the safety of third parties working in proximity to its pipeline.

The Board found that Alliance has developed goals for the prevention of ruptures, fatalities and injuries but has not developed goals for the response to incidents and emergency situations. The Board also found that Alliance goals for the prevention of liquid and gas releases is limited to its pipeline ROW and does not include its aboveground facilities.

Based on the Board’s evaluation of Alliance’s Crossings program against the requirements, the Board has determined that Alliance is Non-Compliant with this sub-element. Alliance will have to develop corrective actions to address the described deficiencies.

Compliance Status: Non-Compliant

2.4 Organizational Structure, Roles and Responsibilities

Expectations:

The company shall have a documented organizational structure that enables it to meet the requirements of its management system and its obligations to carry out activities in a manner that ensures the safety and security of the public, company employees and the pipeline, and protection of property and the environment. The documented structure shall enable the company to determine and communicate the roles, responsibilities and authority of the officers and employees at all levels. The company shall document contractors’ responsibilities in its construction and maintenance safety manuals.

The documented organizational structure shall also enable the company to demonstrate that the human resources allocated to establishing, implementing and maintaining the management system are sufficient to meet the requirements of the management system and to meet the company’s obligations to design, construct, operate or abandon its facilities to ensure the safety and security of the public and the company’s employees, and the protection of property and the environment. The company shall complete an annual documented evaluation in order to demonstrate adequate human resourcing to meet these obligations.

References:

PCR Part II section 4; OPR sections 6.1, 6.4, 20, 31, 40, 47, 48

Assessment:

The Board expects companies to have a documented organizational structure that enables it to meet the requirements of its obligations to carry out activities in a manner that ensures the safety and security of the public, company employees and the pipeline, and protection of property and the environment.

Organizational Structure

During the audit, Alliance provided documents and records that demonstrated that it had established and maintained documented roles and responsibilities statements related to its Crossings program and activities that applied to all levels within the organization as well as contractors. Alliance’s Public Awareness, Crossing and Damage Prevention programs are managed by the LRCM Team in the Head Office and the field staff who have Crossings related duties report to their respective Area Managers.

Annual Evaluation of Resource Need

Along with a documented organizational structure, the Board expects companies to demonstrate an ongoing ability to sustain its program. The Board requires that companies demonstrate, based on an annual documented evaluation of need, that the human resources required to establish, implement and maintain the programs are sufficient to meet operational and regulatory requirements.

Alliance demonstrated that it has developed a number of corporately required or supported mechanisms for evaluating its resourcing needs, including quarterly and annual meeting, progress reports and work completion reports. In addition, Alliance provided the Board a document entitled Corporate Procedure / Assessment of Need Process which explains the process that Alliance has undergone during 2013 and 2014 to assess and rationalize its resource needs and shape its new organizational design. To demonstrate implementation of this process, Alliance also provided a document entitled Corporate Procedure / Assessment of Need Process – Findings that provided the essential results of the assessment undertaken during 2013 and 2014.

Upon review of these records, the Board found that Alliance has not demonstrated an annual documented evaluation of need that meets the Board’s requirements as these records were exception based and thus the Board could not attest to the comprehensiveness of this review.

For the Crossings program, activities within this program are demand driven and the amount of resources required depends on how much third party activity is occurring in a given time and area. Although these activities are tracked, they are not considered when anticipating staffing needs. In certain regions Alliance has standing contracts with external contractors to conduct locates on its behalf when required. Alliance did not demonstrate that it conducts an evaluation of need for its Crossings program that includes the resources required for the maintenance and continual improvement of the management system.

Summary

The Board found that Alliance had a documented organizational structure and communicates the roles, responsibilities and authorities of the officers and employees at all levels of the company.

The Board found that Alliance had established and implemented several mechanisms for reviewing its Crossings program workforce needs. The Board did not observe any resourcing issues during this audit.

The Board also found that Alliance’s evaluation of need did not specifically account for all staff with Crossings program responsibilities and, therefore, did not demonstrate that the human resources allocated to establishing, implementing and maintaining its management system and meeting its requirements are sufficient.

Based on the Board’s evaluation of Alliance’s Crossing program against the requirements, the Board has determined that Alliance is Non-Compliant with this sub-element. Alliance will have to develop corrective actions to address the described deficiencies.

Compliance Status: Non-Compliant

3.0 IMPLEMENTATION

3.1 Operational Control-Normal Operations

Expectations:

The company shall have an established, implemented and effective process for developing and implementing corrective, mitigative, preventive and protective controls associated with the hazards and risks identified in elements 2.0 and 3.0, and for communicating these controls to anyone who is exposed to the risks.

The company shall have an established, implemented and effective process for coordinating, controlling and managing the operational activities of employees and other people working with or on behalf of the company.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(e)(f)(q), 40, 47, 48

Assessment:

The Board requires that regulated companies have an established, implemented and effective process for developing and implementing corrective, mitigative, preventive and protective controls associated with the hazards and risks identified in elements 2.0 and 3.0, and for communicating these controls to anyone who is exposed to the risks.

Development of Controls

Alliance’s Crossings program is comprised of processes designed to provide controls for the range of hazards introduced by third parties while incorporating the requirements of the PCR. Alliance’s controls, including application-specific examination of the hazards and risks are found within several internal practice and procedures. Review of the LRCM Threat / Hazard Review Practice and the associated process flow chart identified step by step guidance for the crossings application assessment, including the introduction of preventive and protective controls such as:

  • triggers for additional review of third party applications by the Integrity Group;
  • communication standards to notify the third party that additional information is required; or that application has been rejected and why:
  • crossing application processes to account for the variety of potential projects that could take place in proximity to its facilities; and
  • forms to assess vehicle crossing requests which includes the vehicle weight and axles.

Additionally, the audit identified that Alliance`s LCRM group has developed and implemented various practices as controls to protect facilities from potential damage. These activities and initiatives include:

  • One-Call centre participation in each of the areas in which it operates facilities ;
  • the use of the SAP work order system to assign tasks such as ROW marker replacement
  • monthly aerial patrols of the entire ROW; and
  • annual aerial surveys specifically to monitor and changes and new developments along the ROW and the identification of POIs.
Communication of Controls

The Board identified that Alliance communicates its controls for the hazards and risks to the third parties using the technical crossing guidelines and in foreign crossing notification packages, documented crossing agreements as well as proximity agreements for work taking place within the 30 m safety zone. Also, at the time of the audit, the NEB verified that basic safety controls were posted on the Alliance website for those who live and work around its pipeline.

With respect to implementing the identified controls, the Board identified that the crossings application process is managed in the Head Office and the regional field staff were responsible for representing Alliance at the third party project sites. Field staff conduct locates as well as all the crossing related inspections. The Board also noted that Alliance used contractors to supplement its staff complement when required.

Summary

Based on the Board’s evaluation of Alliance’s Crossings program against the requirements, the Board has determined that Alliance is Compliant with this sub-element.

Compliance Status: Compliant

3.2 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 upset or abnormal events). The company shall have an established, implemented and effective process for developing contingency plans for abnormal events that may occur during construction, operation, maintenance, abandonment or emergency situations.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(d)(f)(t), 32, 40, 47, 48

Assessment:

Crossings Program Upset or Abnormal Operating Conditions

Alliance demonstrated through interviews and training records reviewed that its field maintenance staff who conduct crossings are trained in the Incident Command Structure and required to participate in the emergency exercises that take place in their regions twice a year. They are also trained to identify and report upset conditions and intervene if they observe any unsafe work practices occurring around Alliance facilities in order to prevent an upset condition.

Contingency Plans

Under the OPR, companies are required to establish and implement a process for developing contingency plans for abnormal events that may occur during construction, operation, maintenance and abandonment activities. For this sub-element, the Crossings program is directly linked to the Safety Management program that is being concurrently audited with this program. The audit identified that Alliance did not have an established and implemented program level process for developing contingency plans as required by the OPR. As the Board has made a non-compliant finding in that audit which will cause a corrective action plan that addresses this program deficiency to be developed, the Board will not assign further non-compliance in the sub-element. Alliance’s corrective action plan developed to address that finding must specifically and explicitly include actions to address this program’s deficiency.

Summary

Based on the Board’s evaluation of Alliance’s Crossings program against the requirements, the Board has determined that Alliance is Compliant with this sub-element.

Compliance Status: Compliant

3.3 Management of Change

Expectations:

The company shall have an established, implemented and effective process for identifying and managing any change that could affect safety, security or protection of the environment, including any new hazard or risk, any change in a design, specification, standard or procedure and any change in the company’s organizational structure or the legal requirements applicable to the company.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(i), 40, 47, 48

Assessment:

During the audit, Alliance demonstrated that it has developed several standards, procedures, and processes for managing change including and described as follows:

  • Operational Excellence Management System Standard –  Management of Change – describes the key components required to be included in the protection program management of change (MOC) practice;
  • Management of Change for Legal Requirements in CCMS – describes how changes to legal requirements are accounted for; and
  • Field Operations MOC Process – describes how changes at the operational level (i.e. changes to assets, procedures, etc.) are assessed.

In addition and as listed in its ORMS framework provided to the Board, Alliance has indicated that it will be developing a Corporate Management of Change process that is still being formalized.

Based on documentation review and interviews, the Board has determined that Alliance has not met the requirements of OPR, section 6.5(i) for the following reasons:

  • The aforementioned standards, procedures and processes function independently of one another and thus are not systematic;
  • Changes to organizational structure are not accounted for in these standards, procedures and processes.
  • While the Field Operations MOC Process is adequately designed, Alliance could not demonstrate that it is being consistently implemented as prescribed.
    As one example, the process requires that environmental checklists are to be completed for every asset based change. Records reviewed during the audit did not contain these checklists.

The Board notes that the OPR requires a company to develop a management system MOC process that identifies and manages any change that could affect safety, security or the protection of the environment. Further the Board notes that, while a company may have multiple processes, there still must be consistency in process requirements, development and implementation as well as coordination of the various practices in order to meet the OPR requirements and to ensure formal management.

Summary

The Board found that, while Alliance had implemented some aspects of an MOC process and was in the process of implementing a new process, it did not demonstrate that it had established and implemented a process that meets the requirements of the OPR.

Based on the Board’s evaluation of Alliance’s Crossing program against the requirements, the Board has determined that Alliance is Non-Compliant with this sub-element. Alliance will have to develop corrective actions to address the described deficiencies.

Compliance Status: Non-Compliant

3.4 Training, Competence and Evaluation

Expectations:

The company shall have an established, implemented and effective process for developing competency requirements and training programs that provide employees and other persons working with or on behalf of the company with the training that will enable them to perform their duties in a manner that is safe, ensures the security of the pipeline and protects the environment.

The company shall have an established, implemented and effective process for verifying that employees and other persons working with or on behalf of the company are trained and competent, and for supervising them to ensure that they perform their duties in a manner that is safe, ensures the security of the pipeline and protects the environment. The company shall have an established, implemented and effective process for making employees and other persons working with or on behalf of the company aware of their responsibilities in relation to the processes and procedures required by the management system or the company’s protection programs.

The company shall have an established, implemented and effective process for generating and managing training documents and records.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(j)(k)(l)(p), 40, 47, 48

Assessment:

The Board expects regulated companies to have an established, implemented and effective process for developing competency requirements and training programs that provide employees and other persons working with or on behalf of the company with the training that will enable them to perform their duties in a manner that is safe, ensures the security of the pipeline and protects the environment.

Developing Competency Requirements and Training Programs

Alliance has developed a Learning and Development Management System that applies to the entire Alliance organization and consists of the following five programs: Onboarding, Training, Competency, Performance Support and Leadership. To administer training and competency evaluation, Alliance utilizes an additional system referred to as the Online Learning Environment (OLE). The system provides the mechanism to register, deliver, track and record learning completions. The OLE also contains requirements for onboarding, training and operations competency that includes skills, knowledge and attributes that an employee-partner needs in order to be considered qualified or capable of performing a specific task. Supporting OLE is an Alliance Competency Evaluation (ACE) program and competency evaluation process that is intended to ensure field maintenance technicians are trained and competent to perform their daily tasks in a safe and effective manner.

The Board verified the following:

  • Alliance’s training program for all Crossings Program employee-partners is managed and maintained by the Learning and Development Team. In addition to the required training for field staff, any employee partner with locating responsibilities is enrolled in the ACE program that was developed and managed by the Alliance Damage Prevention group.
  • Competencies for locating are identified, managed and tested through the ACE competency program.
  • There are no practices or processes specific to the Crossings program that defines a process for developing competencies.
  • Alliance also has developed a corporate-wide competency library that it applies to all employee partners within the accountability agreements. Alliance’s competency library does not include technical skills such as those listed as part of the ACE program or the demonstrated ability to perform technical tasks safely. Instead, the Competency Library lists high-level general personal traits such as “results orientation”.
Managing Training Records

Through a sampling of records across the organization, the Board verified that training records for the Crossing program are managed in the OLE training system and are managed by the Learning and Development Team.

Summary

The Board found that Alliance has an established and implemented process for evaluating the competency with annual evaluations of performance of those employee-partners who conduct locates.

The Board also found that Alliance demonstrated that it manages training records as it pertains to the Crossings program.

The Board has found that Alliance has not established and implemented a process for developing competencies and training programs.

Based on the Board’s evaluation of Alliance’s Crossing program against the requirements, the Board has determined that Alliance is Non-Compliant with this sub- element. Alliance will have to develop corrective actions to address the described deficiencies.

Compliance Status: Non-Compliant

3.5 Communication

Expectations:

The company shall have an established, implemented and effective process for the internal and external communication of information relating to safety, security and environmental protection. The process should include procedures for communication with the public, company employees, contractors, regulatory agencies and emergency responders.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(m), 40, 47, 48

Assessment:

Internal Communication

The Board found that, at the department level, Alliance demonstrated that it has a documented communication plan that supports the effective implementation and operation of the safety and loss management system.

The Board found that, at the department level, Alliance demonstrated an established internal process for communicating information relating to its Crossings program and the evaluation of requests from third parties. Alliance was able to demonstrate that there was both formal and informal internal communication occurring between all of the LRCM groups. For example, Board review of records identified that there were regular meetings occurring where internal initiatives were discussed. During the audit, there were several examples identified that demonstrated that operational information was communicated both within the LRCM and between other Alliance groups. For example, internal announcements regarding regulatory changes are posted on Alliance’s intranet site and re-iterated during LRCM meetings, and the LCOR group attends daily conference calls from Gas Control to discuss operational matters.

External Communication

During the audit, Alliance indicated that its external communication within the LRCM for the Crossings program is limited to the request for permission process. Alliance’s Public Awareness program is responsible for the execution of the majority of the external communication plan. The Crossing program had defined its communications requirements and identified practices to communicate and manage communication with its external stakeholders, for example:

  • Alliance informs third parties of the requirements to arrange for on-site supervision of projects occurring on its ROW;
  • Alliance includes safe practices when working around pipelines, crossings and emergency policy and contact information on its external website;
  • Alliance has signage along its ROW to indicate the presence of the pipeline. Document review confirmed that the condition of the signage is monitored in its monthly aerial patrols;
  • Alliance communicates its requirements for each third party request for permission within the Foreign Crossing Notice package; and
  • Alliance’s involvement with organizations such as provincial One-Call Centres and Common Ground Alliance organizations.
Summary

The Board found that, at the Department level, Alliance demonstrated that it has a documented communication plan that supports the effective implementation and operation of the safety and loss management system.

The Board found that Alliance had established external communication practices applicable to its Crossings program that identified the appropriate stakeholders and developed messages relating to the maintenance of the safety and security of the pipeline and the protection of the environment while working around its pipeline.

Based on the Board’s evaluation of Alliance’s Crossings program against the requirements, the Board has determined that Alliance is Compliant with this sub-element.

Compliance Status: Compliant

3.6 Documentation and Document Control

Expectations:

The company shall have an established, implemented and effective process for identifying the documents required for the company to meet its obligations to conduct activities in a manner that ensures the safety and security of the public, company employees and the pipeline, and protection of property and the environment. The documents shall include all of the processes and procedures required as part of the company’s management system.

The company shall have an established, implemented and effective process for preparing, reviewing, revising and controlling documents, including a process for obtaining approval of the documents by the appropriate authority. The documentation should be reviewed and revised at regular and planned intervals.

Documents shall be revised where changes are required as a result of legal requirements. Documents should be revised immediately where changes may result in significant negative consequences.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(i)(n)(o), 6.5(3), 40, 47, 48

Assessment:

As part of its demonstration, Alliance pointed the Board to their CCMS and the systems supporting documentation as its established and implemented process for identifying the documents required for the company to meet its obligations under OPR, section 6. Upon review, the Board determined that these documents do not include the steps to determine what types of documents are required but focuses on how to use the CCMS. As a result, Alliance was unable to demonstrate that it has established and implemented a Crossings program process to meet the requirements of OPR. The Board notes that while a process deficiency currently exists, the Board did confirm through documentation review that Alliance has developed documents that would be typically be expected for a company of its size and to the scope, nature and complexity of its activities.

Through its Managing Controlled Documents Procedure, Alliance demonstrated that it has established and implemented a Crossings program process for the preparing, reviewing, revising and controlling documents including a process for obtaining approval of its documents. In addition and mentioned previously in this report, Alliance has developed a Technical Document Hierarchy that defines the type of documents that can be created within Alliance’s organization. The Board notes that these definitions align with the Board requirements.

Despite the assessment mentioned above, the Board did find a deficiency with Alliance’s process for reviewing documents. While Alliance’s process does stipulate that the reviews of documents are to occur, it does not define a revision schedule. The Board notes that all documents provided during the audit were current based on normal, acceptable industry best practices. However, to ensure that documents remain current in the future, the Board requires that a defined revision schedule be incorporated into this process.

Summary

The Board found that Alliance had established and implemented a Crossings program process for preparing, reviewing, revising and controlling its documents. However, this process does not include defined revision schedules for its documents.

The Board also found that Alliance had not established and implemented a Crossings program process for identifying the documents required for the company to meet its obligations under OPR section 6.

The Board found that Alliance has developed documents that would be typically expected for a company of its size and to the scope, nature and complexity of its activities.

Based on the Board’s evaluation of Alliance’s Crossings program against the requirements, the Board has determined that Alliance is Non-Compliant with this sub-element. Alliance will have to develop corrective actions to address the described deficiencies.

Compliance Status: Non-Compliant

4.0 CHECKING AND CORRECTIVE ACTION

4.1 Inspection, Measurement and Monitoring

Expectations:

The company shall have an established, implemented and effective process for inspecting and monitoring the company’s activities and facilities to evaluate the adequacy and effectiveness of the protection programs and for taking corrective and preventive actions if deficiencies are identified. The evaluation shall include compliance with legal requirements.

The company shall have an established, implemented and effective process for evaluating the adequacy and effectiveness of the company’s management system, and for monitoring, measuring and documenting the company’s performance in meeting its obligations to perform its activities in a manner that ensures the safety and security of the public, company employees and the pipeline, and protection of property and the environment.

The company shall have an established, maintained and effective data management system for monitoring and analyzing the trends in hazards, incidents and near-misses. The company shall have documentation and records resulting from the inspection and monitoring activities for its programs.

The company management system shall ensure coordination between its protection programs, and the company should integrate the results of its inspection and monitoring activities with other data in its hazard identification and analysis, risk assessments, performance measures and annual management reviews, to ensure continual improvement in meeting the company’s obligations for safety, security and protection of the environment.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(g)(s)(u)(v), 40, 47, 48

Assessment:

The Board expects companies to have an established, implemented and effective process for inspecting and monitoring the company’s activities and facilities to evaluate the adequacy and effectiveness of the protection programs.

Inspection and Monitoring

The Board found that Alliance’s field staff was undertaking inspections to verify that third parties had completed the approved work in accordance with the agreements and Alliance’s established standards. Through document and record reviews and interviews in the regions, the Board confirmed that Alliance staff were aware of the inspection and reporting requirements and were undertaking inspections of crossings and maintaining records of those inspections as required by the PCR. The Board did not note any issues with the post-crossing inspection processes. However, as required by section 53 of the OPR, Alliance was not able to demonstrate that it was conducting inspections to ensure compliance with the NEB Act, the OPR and the terms and conditions of any certificate or order issued by the Board, as they relate to the protection of property, the environment and the safety of the public and of the company’s employees.

ROW Patrol

The Board verified that Alliance is conducting monthly aerial patrols of its entire right of way and has a contract with a third party to conduct a monthly fixed wing patrol. In addition, annual patrols to monitor urban development and other specific threats are also conducted. Interviews confirmed that these flights are attended by an observer and that these contractors are submitting reports. All issues identified by inspections such as downed pipeline markers are tracked and addressed through a company work order system. The Board confirmed that inspection records were being generated and a review of a sample of aerial inspection reports identified that they included confirmation that each of the CSA Z662-11 Clause 10.6.11 conditions and activities were being monitored or assessed during flights.

At the time of the audit, interviews with the pilots indicated that they submitted all reports in approximately 24-36 hours following the inspection. However, according to Alliance’s aerial patrol practice, any unauthorized activity is to be reported to Gas Control within two hours. The company said that there is an expected level of “common sense” on the part of the pilot and that they would know “what couldn’t wait to be reported to gas control”. As a result, the Board notes the practice being implemented was inconsistent with the written procedures because there was no process for emergency reporting of unauthorized activity that had the potential to damage the pipeline. Further to this, Alliance could not demonstrate that it has provided adequate training to its contract pilots given that it expects them to be able to identify potential emergencies. Although the company is confident that the pilots would be able to identify an emergency, such as exposed pipe and discoloured vegetation, Alliance could not demonstrate that the pilots were aware of this expectation. Due to the nature of these deficiencies, the Board requested that a corrective action plan be developed and implemented ahead of the audit close-out. Alliance has reviewed and revised its aerial patrol expectations with its contract pilots to incorporate procedures for reporting of potentially dangerous third party activities on the ROW. In addition, the Board also verified that Alliance has a documented practice to conduct ground patrols for critical or unusual conditions. However, Alliance has yet to implement this practice.

Surveillance and Monitoring Program

The OPR requires companies to develop and implement a surveillance and monitoring program. During its audit the Board identified that Alliance undertakes numerous types of inspections of third party activity and on its ROW. The Board found, however, that the amalgamation of activities do not meet the OPR section 39 program requirements with respect to design and management. The Board has included its program requirements with Section 1.0 Audit Terminology and Definitions in the attached audit report.

Summary

The Board found that Alliance conducted inspections of third party activities in accordance with the requirements of the PCR, Part II.

The Board found that Alliance was not conducting inspections to verify compliance to its legal requirements.

The Board also found that Alliance had not developed a surveillance and monitoring program that meets the requirement of OPR section 39.

The Board also found that Alliance did not demonstrate the effectiveness of the ROW patrol and other inspection practices based on reporting practice. The Board determined that Alliance did not have effective aerial patrol procedures implemented for the reporting of potentially unauthorized activity on its ROW.

Steps were taken to address at the time of the audit that will be in place ahead of the corrective action plan implementation.

Based on the Board's  evaluation of Alliance's Crossings program against the requirements, the Board has determined that Alliance is Non-Compliant with this sub-element. Alliance will have to develop corrective actions to address the described deficiencies.

Compliance Status: Non-Compliant

4.2 Investigating and Reporting Incidents and Near-misses

Expectations:

The company shall have an established, implemented and effective process for reporting on hazards, potential hazards, incidents and near-misses, and for taking corrective and preventive actions. This should include conducting investigations where required or where hazards, potential hazards, incidents and near-misses have or could have resulted in the safety and security of the public, company employees and the pipeline, and protection of property and the environment, being significantly compromised.

The company shall have an established, maintained and effective data management system for monitoring and analyzing the trends in hazards, incidents and near-misses.

The company should integrate the results of its reporting on hazards, potential hazards, incidents and near-misses with other data in hazard identification and analysis, risk assessments, performance measures and annual management reviews, to ensure continual improvement in meeting the company’s obligations for safety, security and protection of the environment.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(r)(s)(u)(w)(x), 40, 47, 48, 52

Assessment:

The Board requires that companies have an established process for reporting on hazards, potential hazards, incidents and near-misses that occur on its regulated facilities. The Board also expects companies to have an established, maintained and effective data management system for monitoring and analyzing the trends in hazards, incidents and near-misses.

Reporting on hazards, potential hazards, incidents and near-misses

The Board found that the internal reporting process is managed through a corporate level database. Through document and record reviews, the Board confirmed that Alliance had implemented a procedure for reporting and tracking third party unauthorized activities. Alliance demonstrated that, once notified, Alliance’s Public Awareness personnel conduct a follow-up investigation on each reported item including unauthorized activities, to determine if damage to the facilities or environment had occurred and to provide additional public awareness material.

Alliance demonstrated that unauthorized activities are reported and tracked through a company software system until resolved and once resolved, unauthorized activities are documented for long-term tracking. Follow-up for unauthorized activity is the responsibility of the Public Awareness program and includes a communication package. According to the process, Alliance personnel will visit with third parties as required to provide additional awareness.

Trending and Analysis

The Board expects companies to have an established, maintained and effective data management system for monitoring and analyzing the trends in hazards, incidents and near-misses.

The Board verified that unauthorized activities are managed, tracked and incorporated into an annual report and are reported into the Alliance data management systems for retention and tracking. No issues were identified with Alliance’s present or proposed practices.

Summary

The Board found that Alliance had established and was maintaining a database for tracking unauthorized activities and monitoring and analyzing the trends in its hazards, incidents, and near-misses for the Crossings program.

Based on the Board’s evaluation of Alliance’s Crossings program against the requirements, the Board has determined that Alliance is Compliant with this sub-element.

Compliance Status: Compliant

4.3 Internal Audits

Expectations:

The company shall have an established, implemented and effective quality assurance program for its management system and for each protection program, including a process for conducting regular inspections and audits; and for taking corrective and preventive actions if deficiencies are identified. The audit process should identify and manage the training and competency requirements for staff carrying out the audits.

The company should integrate the results of its audits with other data in hazard identification and analysis, risk assessment, performance measures and annual management review, to ensure continual improvement in meeting the company’s obligations for safety, security and protection of the environment.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(w)(x), 40, 47, 48

Assessment:

The Board expects companies to have an established, implemented and effective quality assurance program for each protection program, including a process for conducting regular inspections and audits and for taking corrective and preventive actions if deficiencies are identified.

Quality Assurance Program

The specific requirements for establishing and implementing a quality assurance program are found within the OPR. As noted elsewhere in this report, the Crossings program aligns with requirements found within the OPR required Safety and Integrity Management programs. As such, the Crossings program quality assurance management practices must be accounted for in those, or a separate quality assurance program. While Alliance did demonstrate through its Annual Accountable Officer Report that it was undertaking quality assurance activities, Alliance did not demonstrate that it has a quality assurance program applicable to its Crossings programs.

Internal Audits

The Board verified that Alliance’s internal audit group conducted an audit of its Crossings program in 2013 to assess whether it was being implemented as described in its procedures. The scope also included training of staff and some regulatory requirements; however, this conformance audit did not include an assessment of compliance to all regulatory requirements. Interviews with Alliance representatives also indicated that Alliance does not have a practice or process to conduct scheduled audits of the Crossings program to meet the Board’s requirements.

The Board verified that findings from this audit were tracked through the Alliance work-order system to be resolved.
Summary

The Board found that Alliance had not established or implemented a quality assurance program that meets the Board’s requirements.

Although it had conducted an audit of its Crossings program, the Board found that the program had not been audited as per the Board’s requirements.

The Board also found that Alliance had not developed processes for conducting regular audits that meet the Board’s requirements.

Based on the Board’s evaluation of Alliance’s Crossings program against the requirements, the Board has determined that Alliance is Non-Compliant with this sub-element. Alliance will have to develop corrective actions to address the described deficiencies.

Compliance Status: Non-Compliant

4.4 Records Management

Expectations:

The company shall have an established, implemented and effective process for generating, retaining, and maintaining records that document the implementation of the management system and its protection programs, and for providing access to those who require them in the course of their duties.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(p), 40, 47, 48

Assessment:

The Board requires companies to have an established, implemented and effective process for generating, retaining, and maintaining records that document the implementation of the management system and its protection programs, and for providing access to those who require them in the course of their duties.

To demonstrate its compliance, Alliance provided the following documents:

  • Record and Information Management Policy;
  • Document and Records Management Program;
  • Records Management Practice; and
  • Functional Records Classification and Retention Schedule.

The Board found that while the specific OPR process requirements to generate, retain and maintain records to document the implementation of the management system and the protection programs could be accounted for by reviewing these documents in their totality, the Board requires that a singular management system process be established and implemented to ensure ease of use and understanding amongst company employees. Further, Alliance has developed an internal document hierarchy, which includes when processes (among other type of documents) should be developed and how these documents are defined. The Board reviewed this definition and it determined that it does align with the Board expectations; however, it is not been used consistently in the organization.

Despite the process deficiency, the Board verified that Alliance has a number of established practices for records retention. Alliance has several databases for locate requests, third party requests for permissions, land tract profiles, unauthorized activities, right of way issues and crossing inspection reports. Alliance maintains a geographic information system to manage and document work conducted on the right of way and is accessible to field staff. This database can also be leveraged to manage stakeholder contact information for its Public Awareness and Emergency Management programs.

Summary

The Board found that Alliance had implemented consistent records management practices to document the implementation of its Crossings program.

The Board also found that Alliance has not established and implemented a Crossings program process that meets the OPR requirements.

Based on the Board’s evaluation of Alliance’s Crossings program against the requirements, the Board has determined that Alliance is Non-Compliant with this sub-element. Alliance will have to develop corrective actions to address the described deficiencies.

Compliance Status: Non-Compliant

5.0 MANAGEMENT REVIEW

5.1 Management Review

Expectations:

The company shall have an established, implemented and effective process for conducting an annual management review of the management system and each protection program and for ensuring continual improvement in meeting the company’s obligations to perform its activities in a manner that ensures the safety and security of the public, company employees and the pipeline, and protection of property and the environment. The management review should include a review of any decisions, actions and commitments which relate to the improvement of the management system and protection programs, and the company’s overall performance.

The company shall complete an annual report for the previous calendar year, signed by the accountable officer, that describes the performance of the company’s management system in meeting its obligations for safety, security and protection of the environment and the company’s achievement of its goals, objectives and targets during that year, as measured by the performance measures developed under the management system and any actions taken during that year to correct deficiencies identified by the quality assurance program. The company shall submit to the Board a statement, signed by the accountable officer, no later than April 30 of each year, indicating that it has completed its annual report.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(w)(x), 6.6, 40, 47, 48

Assessment:

(Note – The sub-element is attributed to companies’ senior management and Accountable Officer; therefore, the Board does not break up its review into governance and program levels.)

Annual Management Review of Management System and Crossings Program Process

Alliance currently has several processes, practices and activities for conducting an annual management review of its management system and Crossings program as follows:

  • Accountable Officer Report Process;
  • Operational Excellence Management System – OEMS Management Review Process;
  • Land, Right of Way & Corridor Management (LRCM)Annual Program Review Practice

Upon review of the processes, practices and activities, as well as records supporting implementation of an annual management review, the Board noted the following:

  • Accountable Officer Report Process
    • At the time of the audit, the process was not established as per the Board’s working definition, as the document was approved in June 2015. However, interviews confirmed it implemented by practice in order to prepare the 2014 Annual Accountable Officer Report;
    • The design of the process meets Board’s working definition as it includes the 5 w’s and h approach (who, what, where, when, why and how);
    • Process does account for a review of the management system and Public Awareness program;
    • Process does not stipulate the type of protection program level information that is to be provided as part of the review;
    • Process does not stipulate who is responsible for completing the review of the management system; and
    • Process does not stipulate how the annual management reviews ensure continual improvement in meeting the company obligations to protect the safety and security of the people, the pipeline and for the protection of the environment.
  • OEMS Management Review Process
    • The title refers to a process but the document itself refers to it as procedure;
    • As this process/procedure has been in place since 2008, it does meet the Board’s definition of established and implemented;
    • The design of the process meets Board’s working definition as it includes the 5 w’s and h approach (who, what, where, when, why and how);
    • This review process/procedure is not integrated with the Accountable Officer Report Process referred to above;
    • Records reviewed by the Board verified that a quarterly assertion is conducted by the department owners to ensure that program level processes as they pertain to core functions are adequate and that key measures are on track;
    • Reviews are being completed at the process or department level, which does not ensure performance at the protection program level;
    • Review of the management system is not part of this process; and
    • Department level objectives and key measures within this review process do not align with the management system goals, objectives and targets established through Alliance’s practice as referred to in Sub-element 2.3 of this audit report.
  • Land, Right of Way & Corridor Management Annual Program Review Practice
    • As prescribed, this practice is intended to be a conformance check to ensure that LRCM processes are being followed and revised as necessary;
    • This activity is not integrated by process to either the Accountable Officer Report Process and OEMS Management Review Process referred to above; and
    • This practice does not meet the Board’s definition of a process as it does not include the Board’s common 5 w’s and h approach (who, what, where, when, why and how). Further, Alliance has a developed an internal document hierarchy, which includes when processes (amongst other type of documents) should be developed and how it is defined. The Board reviewed this definition and it determined that it does align with the Board expectations; however, it is not being used consistently in the organization.
Management System Evaluation Process

While the Board has listed this requirement under sub-element 4.1 of the Protocol, Alliance indicated during the audit that its Accountable Officers Report Process is also used to evaluate the adequacy and effectiveness of the company’s management system. In reviewing the content of this process and as set out above the Board notes the following:

  • At the time of the audit, the process was not established as per the Board’s working definition as the document was approved in June 2015. However, interviews confirmed it implemented by practice in order to prepare the 2014 Accountable Officer Report;
  • The design of the process meets Board’s working definition as it includes the 5 w’s and h approach (who, what, where, when, why and how); and
  • Process does not explicitly indicate how the adequacy and effectiveness of the company’s management system is evaluated and this would need to be inferred through several activities within the process.

Based on the Board’s evaluation of Alliance’s management system and Crossings program against the requirements, the Board has determined that Alliance has not established and implemented a process for evaluating the adequacy and effectiveness of its management system. Alliance will have to develop corrective actions to address the described deficiencies.

Annual Report

According to OPR section 6.6, Alliance must complete its annual Accountable Officer Report, have it signed by the accountable officer, and submit confirmation of completion to the Board no later than April 30 each year. The Board confirmed that the Accountable Officer Report for the 2014 performance year was signed by the accountable officer and confirmation of completion was submitted to the Board on April 17, 2015.

Alliance develops an annual Accountable Officer Report that summarizes the performance of its OEMS and supporting protection programs. Alliance divides the report into five main parts:

  • Overview of protection programs and management systems;
  • Performance management: management system goals and results;
  • Quality assurance;
  • Progress against the previous year’s improvement recommendations; and
  • Recommendations for the coming year.

Upon review of the annual Accountable Officer Report, the Board noted that the report does describe the performance of the company’s management system in meeting its obligations to ensure the safety and security of the people, the pipeline and the protection of the environment. In addition, the report also describes the company’s achievement of its established goals, objectives and targets. The annual Accountable Officer Report also includes a section that describes the quality assurance activities that occurred in that year. However, Alliance’s annual Accountable Officer Report does not specify the actions taken during that year to correct any deficiencies identified by the quality assurance program. Thus, it is unclear whether the accountable officer is aware of these actions and deficiencies.

Management Responsibility

Further to the review of these processes and activities, the Board notes that Alliance has not conducted audits consistent with its OPR and CSA obligations. The Board views the responsibility for undertaking these audits as resting with the company’s senior management (as represented by its accountable officer) as the annual report developed as per OPR specifically requires review and reporting on aspects of the Quality Assurance Program (specifically including audits) and the performance of the management system in meeting its obligations under OPR section 6.

Summary

The Board found that Alliance had developed processes for and undertaken activities relating to its Management Review responsibilities.

The Board also found that Alliance’s processes did not meet all of the requirements outlined in the OPR.

The Board also found that some of the Non-Compliant findings in this audit are related to sub-elements where Alliance’s Senior Management has responsibilities to ensure that management direction, oversight and formal monitoring are occurring.

Based on the Board’s evaluation of Alliance’s Crossing program against the requirements, the Board has determined that Alliance is Non-Compliant with this sub-element. Alliance will have to develop corrective actions to address the described deficiencies.

Compliance Status: Non-Compliant

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