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Appendix IFootnote i

Emergency Management 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.

References:

OPR section 6.2

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 management system and Emergency Management 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:

OPR section 6.3

Assessment:

Management System Policies and Policy Statement

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.

(Note: While “goals” are included in this sub-element’s description, for clarity and organization, the review of goals is documented in sub-element 2.3 Goals, Objectives, Targets)

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 regulation. 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.

The Board also notes that during the audit, Alliance was in the process of revising its management system to explicitly account for the OPR requirements. An updated framework was provided to the Board and while additional time is required to fully establish, implement and maintain its management system, Alliance was able to demonstrate that its management system is based upon the established policies referred to above and as required by OPR, section 6.3(2).

Emergency Management Program Policy

Alliance referenced its Health & Safety Management System (HSMS) as being equivalent to the OPR required program for Emergency Management. Interviews with emergency and safety management personnel indicated there is no specific Emergency Management program policy at Alliance.

Alliance referenced an established Health & Safety Policy that ensures the safety and security of the public and the company’s employees. This policy is made available through the company internal intranet and was also posted at all offices visited by the Board during the audit. Through interviews and documentation review, Alliance demonstrated its Emergency Management program is based upon this policy.

Summary

The Board found that Alliance has developed policies and policy statements to meet the requirement of OPR, section 6.3(1). The Board found that Alliance has based its management system and Emergency Management program on 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 management system and Emergency Management 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:

OPR section 6.5(1)(c)(d)(e)(f)(r)(s)

Assessment:

Management System Hazards and Potential Hazards Identification Process

At the time of the audit, the identification of hazards and potential hazards was being completed at the various protection program levels and not by an established and implemented management system process as required by OPR, section 6.5(1)(c). Alliance did demonstrate through its revised ORMS framework that it is in the process of developing a hazard identification process. The Board notes that while a management system deficiency currently exists, the Board did verify that hazards are being identified through established program level practices.

Management System Hazard and Potential Hazard Inventory

At the time of the audit, Alliance did not demonstrate that it has established and maintained an inventory of hazards and potential hazards at the management system level. The Board has verified that various inventories have been established at the protection program level and this is this described in the sections below.

Management System Evaluating and Managing Risk Process

At the time of the audit, the evaluation and managing of risks was being primarily completed at the various protection program levels and not by an established and implemented management system process as required by OPR, section 6.5(1)(e). Alliance did demonstrate it has developed a corporate risk matrix for each of the protection programs to use to guide risk ranking and prioritization of identified hazards and that risks are reviewed during management review meetings. Alliance has also demonstrated that through its revised ORMS framework that it is in the process of developing a risk assessment and control process. The Board notes that while a management system deficiency currently exists, the Board did verify that risks are being evaluated and managed through established protection program level practices.

Emergency Management  Program Hazard and Potential Hazard Identification and Risk Assessment Process

Alliance referenced the following documents as supporting the requirement for a process for identifying and analyzing all hazards and potential hazards: it’s Emergency Response Program, the HSMS, several health and safety practices and the Risk Management Program for Integrity. 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. In addition, while Alliance has established and implemented various documented practices at the Emergency Management program level, these documents do 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 to this, Alliance has developed an internal document hierarchy, which includes when a process (among other types of documents) should be developed and how it is defined. The Board reviewed this definition and determined that it does align with the Board expectations; however, it is not been used consistently in the organization.

Emergency Management Program Hazard and Potential Hazard Inventory

Through its existing practices, Alliance demonstrated that it is has established several inventories of hazards within the Health & Safety Program, Environment and Integrity program that are subsequently evaluated from a risk perspective and then managed through appropriate controls. However, the Board notes that these inventories do not compile into an inventory for the Emergency Management program.

Summary

The Board has found that Alliance has not established and implemented a documented management system process for the identification of hazards and potential hazards as required by the OPR.

The Board also found that while a management system deficiency currently exists, the Board did verify that key hazards are being identified and controlled through established Emergency Management program level practices.

The Board found that Alliance did not demonstrate that it has established and maintained an inventory of hazards and potential hazards at the management system level.

The Board also found that Alliance established various inventories at the Emergency Management program level but do not comprise an Emergency Management hazard and potential hazard inventory.

The Board found that Alliance has not established and implemented a documented management system for the evaluation and managing of the risks associated with the identified hazards.

The Board found that Alliance’s Emergency Management program practices do not meet the OPR requirements with respect to process design and implementation.

Based on the Board’s evaluation of Alliance’s management system and Emergency Management 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

2.2 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:

OPR section 6.5(1)(g),(h),(i)

Assessment:

Management System Identifying Legal Requirements Process

As part of their 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 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 Management System Legal List below for additional details.

Management System Monitoring Compliance with Legal Requirements Process

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, 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 management system 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 protection program level practices.

Management System and Emergency Management Program Legal List

As noted earlier, Alliance has developed a centralized electronic library, CCMS, in order to the meet the OPR requirements to establish and 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 OPR, section 6.5(1)(h).

Emergency Management Program Identifying and Monitoring Compliance to Legal Requirements Process

Alliance’s HSMS includes an element on legal and regulatory assessment of which Alliance has developed a documented practice that outlines the requirements to identify, record, and maintain health and safety legal requirements. Several techniques are used to track, identify, and evaluate applicable laws and regulations, including commercial databases and periodicals, information from trade associations, direct communication with national and provincial/state regulatory agencies, and periodic refresher training on health and safety legislation and regulation. The Board also verified through interviews that Alliance utilizes third parties to provide up-to-date regulatory information and updated copies of applicable health and safety laws and regulations.

Alliance demonstrated that it has accounted for the majority of its emergency management legal requirements within the Emergency Management program and response plans. These legal requirements are being monitored and reviewed during its document management process. The Board reviewed these documents and associated records during the audit and found that Alliance had been implementing the practices as designed.

While Alliance has established and implemented a documented practice at the Emergency Management program level, this document 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 to this, Alliance has developed an internal document hierarchy, which includes when a process (among other type of documents) should be developed and how it is defined.

The Board reviewed this definition and determined that it does align with the Board expectations; however, it is not been used consistently in the organization.

Summary

The Board found that Alliance has not established and implemented a documented management system process for identifying and monitoring compliance with applicable legal requirements and thus is in non-compliance with OPR, section 6.5(1)(g).

The Board also found that Alliance has established and maintained a legal list that includes its federal and provincial requirements. However, this legal list does not include referenced standards and thus is in non-compliance with OPR, section 6.5(1)(h).

The Board found that Alliance’s Emergency Management program practices does include the identification and monitoring of compliance with applicable emergency management legal requirements.

The Board also found that Alliance’s Emergency Management program practices do not meet the OPR requirements with respect to process design and implementation.

Based on the Board’s evaluation of Alliance’s management system and Emergency Management 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:

OPR sections 6.3, 6.5(1)(a),(b), 6.6

Assessment:

Management System Goals

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 right-of-way 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.

The Board also notes that during the audit, Alliance was in the process of revising its management system to explicitly account for the OPR requirements. An updated framework was provided to the Board and while additional time is required to fully establish, implement and maintain its management system, Alliance was able to demonstrate that its management system is based upon the established goals referred to above and as required by OPR, section 6.3(2).

Management System Objectives and Targets Process

At the time of the audit, the process for developing objectives and targets was being completed at the various protection program levels and not by an established and implemented management system process as required by OPR, section 6.5(1)(a). Alliance did demonstrate through its revised ORMS framework that it is in the process of developing annual goals, objectives and target setting process.

The Board notes that while a management system deficiency currently exists, the Board did verify that objectives and targets are being identified through established practices. As demonstrated in its annual Accountable Officer Report, Alliance has established strategic management goals, objectives, measures and targets that are reviewed annually.

Management System Performance Measures

Alliance has developed performance measures for assessing the company’s success in achieving its goals, objectives, and targets and this was demonstrated in the company’s annual Accountable Officer Report.

Emergency Management Program Goals, Objectives and Targets Process and Performance Measures

Alliance references the HSMS practice for addressing the Emergency Management Program goals, objectives and targets. The objectives and targets are established through review and approval by the Health, Safety and Environment Management Committee (HSEMC) and once established, these objectives and targets are reviewed for performance on at a least a semi-annual basis with a final review being conducted in advance of preparing the annual Accountable Officer Report. Through documentation review and interviews, the Board verified that these objectives and targets were appropriate for the Emergency Management program and that the practice was being implemented as prescribed.

The Board notes that while Alliance has established and implemented a documented practice, this document 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 to this, Alliance has developed an internal document hierarchy, which includes when a process (among other type of documents) should be developed and how it is defined. The Board reviewed this definition and determined that it does align with the Board expectations; however, it is not been used consistently in the organization.

Summary

The Board found that Alliance has not established and implemented a management system and Emergency Management process for setting objectives and specific targets as required by the OPR.

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’s goals for the prevention of liquid and gas releases is limited to its pipeline right-of-way and does not include its aboveground facilities.

The Board also found that Alliance has based its management system and Emergency Management program on these goals.

The Board found that Alliance has established performance measures to assess the company’s success in achieving its goals, objectives and targets.

Based on the Board’s evaluation of Alliance’s management system and Emergency Management 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:

OPR sections 6.4, 20, 31

Assessment:

Management System Organizational Structure and Roles and Responsibilities

Through Alliance’s ORMS, a documented organizational structure has been established with the President and CEO designated as the Accountable Officer. The ORMS outlines some high level roles and responsibilities of positions within the management system and in more detail in job descriptions, accountability agreements, procedures, organizations and other management system documentation. Communication of roles and responsibilities occurs through policies, procedures, training and regular company and department communications. The Board has found the organizational structure is adequate for the management system, however, as Alliance continues to develop and implement the management system, regular review of the organizational structure needs to be performed.

In addition, the Board verified through record review that employees at all levels have Accountability/Performance Agreements. These agreements are completed annually, approved by both the employee and their leader, documents the employees roles and responsibilities and includes how each employee will support the organization in meeting its corporate goals.

Management System Annual Evaluation of Need

The ORMS outlines Alliance’s commitment to provide adequate resources to establish, implement, maintain and improve the management system. Formal review and planning primarily takes place through management review and the annual management review includes an evaluation of the need for changes including resource requirements.

Alliance demonstrated that it has developed a number of corporately required or supported mechanisms for evaluating its resourcing needs, including quarterly and annual meetings, 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 OPR requirements as these records were exception based and thus the Board could not attest to the comprehensiveness of this review.

The Board also reminds Alliance that the annual evaluation of need has to ensure that resources are sufficient to establish, implement and maintain the management system in order to meet Alliance’s obligations to protect the safety and security of the people, the pipeline and for the protection of the environment. As a result, this evaluation must account for all the activities as well as those employees or other persons working with or on behalf of the company who enable Alliance to meet those requirements. Specifically for the Emergency Management program, Alliance did not demonstrate a documented annual evaluation of need that addresses preparedness (planning, training and testing) and ensures an adequate response (timed response, capable, trained) to credible emergency scenarios for Alliance operations during normal business hours, night-time and during holidays.

Emergency Management Program Organizational Structure and Roles and Responsibilities

Alliance referenced a health and safety practice for the establishment of the emergency management structure, roles and responsibilities outlining key responsibilities of “Emergency Management” including the maintenance of emergency management plans, coordination of emergency response exercises, performing audits and acting as liaison. Alliance demonstrated job descriptions at various levels of the organization that included emergency response roles and responsibilities. The Board verified that Alliance has established an organizational structure for the Emergency Management program.

Summary

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

The Board also found that Alliance did not demonstrate that the human resources allocated to establishing, implementing and maintaining its management system are sufficient to meet the requirements of the management system and to meet the company’s obligations under OPR, section 6.

Based on the Board’s evaluation of Alliance’s management system and Emergency Management 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:

OPR 6.5(1)(e),(f),(q)

Assessment:

The Board notes that the Emergency Management program is designed to address only abnormal or upset operations. This section is therefore considered not to apply in this audit. The review of Alliance’s controls is documented in sub-element 3.2, below.

Compliance Status: N/A

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:

OPR sections 6.5(1)(c)(d)(e)(f)(t)

Assessment:

Management System Developing and Implementing Operational Controls – Abnormal Operations

At the time of the audit, the evaluation and managing of risks for normal operations was being primarily completed at the various protection program levels and not by an established and implemented management system process as required by OPR, section 6.5(1)(e). Similarly, the development and implementing of controls and communicating those controls to those who are exposed to the risks were also being completed at the various protection program levels and not by an established and implemented management system process. Alliance demonstrated that through its revised ORMS framework that it is in the process of developing a risk assessment and control process. The Board notes that while a management system deficiency currently exists, the Board did verify that hazards and risks are being controlled through established protection program level practices.

Management System and Emergency Management Program Processes for Coordinating, Controlling and Managing the Operational Activities of Employees and other People Working With or On Behalf of the Company

The ORMS comprises of several different mechanisms for coordinating and controlling the operational activities and other people working with or on behalf of the company. A review of the ORMS indicated that a formal organizational structure has been established and roles, responsibilities, accountabilities and authorities are detailed in job descriptions, accountability agreements, procedures, organizational charts and other management system documentation.

Alliance indicated that these requirements were further described within its Business Process Description WO Philosophy and Maintenance Planning and its Operations Work Order Management Field Guide. Upon review, the Board found that these documents are focused on the management of the physical and financial performance of operational assets and do not ensure that all operational activities are being coordinating and controlled. As one example, aboveground facility and pipeline right-of-way inspections that are conducted by the protection programs would not be accounted in the practices currently established by Alliance. Alliance is therefore non-compliant with OPR, section 6.5(1)(q).

Management System Developing Contingency Plans for Abnormal Events Process

In its ORMS framework, Alliance has developed an element that is focused on Operational Control – Upset or Abnormal Conditions and references the Emergency Management Program as providing the framework and overview of the processes to identify risks, prevent, mitigate, prepare for, respond to and recover from emergency situations. The Board notes that Alliance has developed several contingency plans such as the Pandemic Preparedness Plan and Corporate/Departmental Business Continuity Plans. However, Alliance was not able to demonstrate that it has established and implemented a documented management system process for developing contingency plans for abnormal events that may occur during construction, operation, maintenance, abandonment or emergency situations.

The Board notes that contingency plans are not limited to emergency response. Therefore, the Board found that Alliance’s management system did not include specific processes or policies for developing contingency plans for abnormal events.

Emergency Management Program Upset or Abnormal Operating Conditions

The Board verified Alliance has developed facility and worksite emergency procedures and practices to address upset or abnormal operating conditions including, but not limited to, medical situations. Alliance has documented its planning requirements and procedures in its Emergency Response Plans, Contractor Safety Manual and within its site-specific plans.

The Board identified that Alliance requires all staff, visitors and contractors to have a safety orientation to the site before they access the site. The company communicates and physically posts facility evacuation and emergency plans at each facility demonstrating that it has and maintains emergency shutdown and response equipment at each worksite. Alliance demonstrated that first aid supplies, including automated external defibrillators, were readily available at appropriate locations. The Board identified through documentation review and interviews that that all of the company’s frontline Operations staff receives first aid training.

During its audit the Board specifically included the review of high risk activities within Alliance’s activities. With respect to this sub-element, the Board identified that Alliance employees and supervisors required to work on gas compressors and electrical switchgear are trained and equipped to perform rescues if required. Additionally, the Board also found that Alliance frontline staff, including managers, has received various levels of Integrated Command Structure (ICS) and first response training needed to fulfill their anticipated roles in the company’s Emergency Response Plans.

Emergency Management Program Process for Developing Contingency Plans for Abnormal Events

Alliance did not demonstrate that it has an Emergency Management program level process that meets the OPR requirements. However, interviews with regional personnel confirmed that Alliance regional staff use and understand the company’s contingency plans for emergency response, first aid and rescue.

Summary

The Board found that Alliance has developed controls that address its identified Emergency Management program hazards and risks relating to upset and abnormal operating conditions.

The Board also found that Alliance has not established and implemented a documented management system process for developing and implementing controls and thus is in non-compliance with OPR, section 6.5(1)(f).

The Board found that Alliance has not established and maintained a documented management system process for coordinating and controlling the operational activities of employees or other people working with or on behalf of the company and thus is non-compliant with OPR, section 6.5(1)(q).

The Board found that Alliance has developed and documented many contingency plans.

The Board also found that Alliance had not established a management system or program level process for developing contingency plans that meets the Board’s requirements.

Based on the Board’s evaluation of Alliance’s management system and the Emergency Management 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

3.3 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:

OPR section 6.5(1)(i)

Assessment:

Management System Management of Change Process

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.

Emergency Management Program Management of Change Process

Alliance’s referenced the HSMS that includes an element on management of change, which Alliance has developed a documented process to ensure that quality decision making occurs in response to a change, that pertinent stakeholders have the opportunity to provide input on the proposed change and to document the efforts conducted during the change process. Upon review, the Board notes this process applies to changes involving systems, plans, practices, procedures and processes owned by Alliance’s Health and Safety department and does not account for all the changes that are to be managed as required by the OPR.

While Alliance has established a documented process at the Emergency Management program level, this document 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). The Board also notes that Alliance could not demonstrate through records that this process has been implemented as prescribed.

Summary

The Board found that Alliance demonstrated that it had established and implemented a number of management of change processes, procedures and practices to document and manage change. However, these processes, practices and procedures function independently of one another and thus are not systematic.

The Board also found that Alliance’s current management of changes activities do not account for changes to the company’s organizational structure as required by the OPR.

The Board found that Alliance has established a management of change process at the Emergency Management program level but it does not account for all the changes that are to be managed as required by the OPR.

The Board also found that Alliance’s Emergency Management program practices do not meet the OPR requirements with respect to process design and implementation.

Based on the Board’s evaluation of Alliance’s management system and Emergency Management 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:

OPR section 6.5(1)(j),(k),(l),(p)

Assessment:

Management System and Emergency Management Program Developing Competencies and Training Programs Process

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.

In reviewing the provided documentation as well as through interviews, the Board notes the following:

  • Alliance has not established and implemented a process for developing competencies and training programs as required by the OPR;
  • Alliance has developed a training program, including a Training Matrix, that applies to all Alliance personnel, which meets the requirements of OPR, section 46;
  • Through the ACE program, Alliance has developed competencies for its field maintenance technicians. However, this is limited to matters of safety. While the Board recognizes this importance, competencies should also be developed for those tasks that involve environmental and emergency management considerations;
  • OLE programs apply to Alliance employees but not to all workers doing activities on behalf of the company. Alliance does manage contractors through a third party prequalification process and a field orientation course. However, this is not accounted for by a management system process; and
  • Alliance’s training department provides support to all protection programs for the development of departmental content and eLearning programs and each department manages the content of programs housed in OLE. The Board verified through front line interviews and inspections that Alliance has implemented the systems to generate, manage and document the various training programs.
Management System and Emergency Management Program Verification of Competency and Training Process

Through interviews and documentation review, the Board found that Alliance has established and implemented a documented management system process to verify that certain employees are trained and competent through its ACE program. However, as it indicated in the previous section, the ACE program is limited to field maintenance technicians and does not include other employees or other persons working with or on behalf of the company. As a result, the Board found Alliance in non-compliance with the OPR requirements.

The Board verified that all formal training within the OLE includes records of training, which are maintained for all training and other activities provided. During the site visits and interviews at each location, the Board was shown updated data on outstanding and scheduled training for the local employees. The Board verified that all training was up to date.

Management System and Emergency Management Program Making Employees aware of Responsibilities Process

Through interviews and documentation review, Alliance pointed to numerous activities (job descriptions, pre-job meetings, etc.) to how this requirement was being met. However, Alliance could not demonstrate that it has established and implemented a documented management system and Emergency Management program process that makes employees and other persons working with or on behalf of the company aware of their responsibilities.

Summary

The Board has found that Alliance has not established and implemented a documented management system and Emergency Management program process for developing competencies and training programs.

The Board also found that Alliance has developed and implemented training programs for all employees and has developed competencies for its field maintenance technicians. However, these competencies are limited to matters of safety and do not include emergency management considerations.

The Board has found that Alliance has established and implemented a documented management system and Emergency Management program process for verifying the competency and training of certain employees within its organization. However, this process does not include all employees or other persons working with or on behalf of the company as required in the OPR.

The Board has also found that Alliance has not established and implemented a documented management system and Emergency Management process to make employees and other persons working with or on behalf of the company aware of their responsibilities.

Based on the Board’s evaluation of Alliance’s management system and Emergency Management 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:

OPR section 6.5(1)(m)

Assessment:

Management System Internal and External Communication Process

During the audit, Alliance demonstrated that it effectively communicates information relating to safety, security and protection of environment to both internal and external stakeholders. Mechanisms that demonstrated this included their internal intranet site, various daily, weekly, monthly and annual meetings and the development of communication plans for each of the protection programs included in this audit. However, Alliance was not able to demonstrate that it has established and implemented a documented process that accounts for all of these activities. The Board notes that during the audit, Alliance was in the process of revising its management system to explicitly account for the OPR requirements and this includes developing a management system communication process.

Emergency Management Program Internal and External Communication

Alliance’s HSMS does include an element on communication, which outlines the requirements for documented plans for internal and external communication regarding health and safety. It is also describes ‘communication management’ as including all personnel under the control of the organization including temporary employees, contractors, sub-contractors, relevant vendors, service providers and visitors. It also includes receiving, recording and responding to external communication from interested parties such as regulatory agencies.

The Board found that through a review of documentation and interviews with Alliance emergency management personnel, there is no formal internal communication process for the Emergency Management program and interviews indicated that internal communication occurs through management meetings, HSE committees, emergency management department personnel (email, telephone calls), however, an overall process has not been established.

The Board also found that while Alliance developed procedures for communication with the public, company employees, contractors, regulatory agencies and emergency responders, it has not established and implemented a documented process for external communication of information relating to safety, security and environmental protection as required by the OPR.

While a process deficiency exists, Alliance did demonstrate through its documented Community and Corridor Stakeholder Engagement Plan that they are communicating with stakeholders such as the affected public, emergency officials, public officials, and excavators along their pipeline right-of-way.

The activities shall be as comprehensive as necessary to reach all areas in which Alliance operates and as examples of this communication, Alliance provided mutual emergency assistance agreements from several of its areas of operation. The Board also found that Alliance records liaison events in a company database for tracking and analysis.

During the audit, Alliance demonstrated that it has established Liaison and Continuing Education activities that include:

  • Structured education presentations in association with meal functions are an effective method to communicate with organized groups such as emergency responders and equipment operators;
  • Guest speaker appearances are effective with property owners groups, civic clubs, etc.;
  • Awareness videos are effective education tools for children’s groups such as scout troops and schools;
  • One-Call center tours are effective for educating the public, news media, facility locators, excavators, and operators about the overall One-Call system and damage prevention process;
  • Involvement of all stakeholder groups in local and regional partner or utility coordinating meetings improves networking opportunities and damage prevention awareness;
  • Agricultural industry forums and events provide a good opportunity to educate farmers and equipment suppliers on the damage prevention message;
  • Contractor and construction trade shows are unique opportunities to deliver the damage prevention public education message; and
  • Training videos and multimedia presentations are effective to reach facility owner/operator locating staffs, customer service personnel, and One-Call center liaisons.

The Board found that Alliance has prepared comprehensive handouts for Emergency Responders that are mailed-out and also provided during presentations and other meetings. Additionally, information is available on the Alliance external website available to anyone that visits the site. Alliance has measured the effectiveness of this communication through the use of a survey with fire departments, police and public officials. While the Board found that a survey could be a valuable tool to obtain feedback, Alliance could not demonstrate through records that it has consulted with the agencies that may be involved in an emergency response in developing and updating its emergency procedures manual.

The Board also found that while Alliance has conducted numerous continuing education activities, these do not constitute a program. The Board has provided clear guidance as part of the guidance notes that accompany the OPR that a program is not simply a description of activities. Programs are: “a documented set of processes and procedures designed to regularly accomplish a result. A program outlines how plans, processes and procedures are linked, and how each one contributes toward the result. Program planning and evaluation are conducted regularly to check that the program is achieving intended results.” The Board’s definition is included in Section 1.0 Audit Terminology and Definitions of the attached audit report.

Summary

The Board found that Alliance communicates throughout its organization and externally as a matter of organized practice.

The Board also found that Alliance has not established and implemented an internal and external communication process that meets the OPR requirements.

The Board has found that Alliance has not adequately consulted with its emergency responders as per the requirements of the OPR.

The Board has found that Alliance has not developed a program that meets the requirements of the OPR for a continuing education program.

Based on the Board's  evaluation of Alliance's  management system and Emergency Management 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

3.6 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:

OPR section 6.5(1)(i)(n)(o), 6.5(3)

Assessment:

Management System and Emergency Management Program Process for Identifying the Documents Required to Meet its Obligations

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 documented management system and Emergency Management program process to meet the requirements of OPR, section 6.5(1)(n). The Board notes that while a management system 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.

Management System and Emergency Management Program Documentation and Document Control

Through its Managing Controlled Documents Procedure, Alliance demonstrated that it has established and implemented a documented management system and Emergency Management program process for the preparing, reviewing, revising and controlling its documents including a process for obtaining approval of the 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 documented management system and Emergency Management process for preparing, reviewing, revising and controlling its documents. However, this process does not include defined revision schedules for its documents and thus is in non-compliance with OPR, section 6.5(1)(o).

The Board also found that Alliance had not established and implemented a documented management system and Emergency Management program process for identifying the documents required for the company to meet its obligations under OPR section 6 and thus in non-compliance with OPR, section 6.5(1)(n).

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 management system and Emergency Management 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:

OPR sections 6.1(d), 6.5(1)(g)(s)(u)(v), 56

Assessment:

Management System Inspection and Monitoring Process

At the time of the audit, the inspection and monitoring of the company’s activities and facilities was being completed at the various protection program levels and not by an established and implemented management system process as required by OPR, section 6.5(1)(u). Alliance did demonstrate through its revised ORMS framework that it is in the process of developing an inspection process. The Board notes that while a management system deficiency currently exists, the Board did verify that inspections are being completed through established program level practices.

Management System and Emergency Management Program Monitoring Compliance with and Inspecting to Legal Requirements

As referred to Sub-element 2.2, Alliance was not able to demonstrate that it has established and implemented a management system process to monitor compliance with applicable legal requirements as documentation provided focused on changes to legal requirements. In addition, OPR section 53 requires companies to conduct inspections on a regular basis to ensure compliance with certain parts of 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. Through documentation review and interviews, Alliance was not able to demonstrate that these inspections were occurring as required.

Management System Corrective and Preventive Actions Process

At the time of the audit, taking corrective and preventive actions if deficiencies are identified through inspections was being completed by Alliance at the various protection program levels and not by an established and implemented management system process as required by OPR, section 6.5(1)(u). The Board notes that while a management system deficiency currently exists, the Board did verify that corrective and preventive actions resulting from inspections are being completed through established program level practices.

Emergency Management Program Inspection and Monitoring Process

Alliance’s HSMS has an element on audits and inspections which provides an overview on Alliance’s approach to conducting inspections as it pertains to the Emergency Management program including equipment and facilities. The Board verified through documentation and a review of records that these activities were not being completed as part of an established process.

The Board found that Alliance has well defined responsibilities across its organization for performing exercises and it has developed the following types of exercises: Drill, Tabletop Exercise, Isolated Functional Exercise, Coordinated Functional Exercise, Full Simulation and Full Scale Exercise.

The Board found that that exercises are performed in each region annually with an internal minimal requirement of one (1) coordinated and one (1) table top. Interviews with Alliance personnel indicated that each region prepares its emergency response scenarios and that Alliance performs reviews and learnings from each exercise. However, the Board found the following deficiencies in relation to Alliance emergency response exercises:

  • There is no coordinated process approach, across the regions, to ensuring adequacy, comprehensiveness and testing of the emergency response plans;
  • Through a review of exercise reports and interviews with personnel involved in exercises, the Board found that the exercises form a basis for ‘training’ but do not have a comprehensive process for evaluating (testing) the exercise execution to determine adequacy and effectiveness of the response; and
  • Alliance could not demonstrate through a review of records the number of events that external agencies have participated in during the past several years. The Board found that Alliance has made efforts to invite emergency responders to exercises; however, the number and/or percentage of actual events is not clear.
Emergency Management Program Corrective and Preventive Action Process

During the audit, Alliance referenced the HSMS for corrective and preventive actions; however, the Board has found that Alliance has not established a process for the Emergency Management program. The Board found that Alliance prepares formal reports after each exercise, which are inputted into an electronic database for tracking. The Board confirmed that corrective actions are tracked through the database as an activity.

Summary

The Board found that Alliance has not established and implemented a documented management system process for inspecting and monitoring the company’s activities and facilities to evaluate the adequacy and effectiveness of the Emergency Management program as required by the OPR.

The Board also found that Alliance did not demonstrate that it was inspecting to its legal requirements as required by the OPR.

The Board found that Alliance was taking corrective and preventive actions for the deficiencies identified through its Emergency Management program inspections and exercises.

The Board found that Alliance has conducted emergency responses exercises. However, the design and implementation of these exercises do not ensure the adequacy and effectiveness of Alliance’s emergency response plan.

Based on the Board’s evaluation of Alliance’s management system and Emergency Management 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:

OPR section 6.5(1)(r)(s)(u)(w)(x), 52

Assessment:

Management System Internal Reporting and Corrective and Preventive Actions Process

At the time of the audit, the internal reporting of hazards, potential hazards, incidents, near misses and the process for taking corrective and preventive actions was being completed at the Emergency Management program level and not by an established and implemented management system process as required by OPR, section 6.5(1)(r). The Board notes that while a management system deficiency currently exists, the Board did verify through interviews and documentation review that hazards, potential hazards, incidents and near misses are being reported and corrective and preventive actions are taken through the Emergency Management program practice.

Management System and Emergency Management Program Data Management System

Through documentation review and interviews, Alliance was able to demonstrate that it has established and maintained a data management system through an internal software application. This application is managed and maintained at the corporate level and allows Alliance employees to report, learn from, evaluate and address events (hazards, near misses and incidents) that occur both in and outside of their workplace. Training on this application is mandatory for all employees and all events that are reported in this application are communicated via email to the entire organization.

During the audit, Alliance provided several demonstrations of this application and demonstrated its ability to monitor and analyze trends in hazards, incidents and near-misses. It was during these demonstrations that the Board verified, through a sampling of events, that corrective actions were developed and implemented.

Emergency Management Program Internal Reporting and Corrective and Preventive Action Process

During the audit, Alliance referred to the Safety Management program documentation and records to demonstrate its internal reporting, corrective and preventive actions practices with respect to this sub-element at the Emergency Management program level. Alliance has established a practice that consolidates and summarizes the health and safety related hazards, potential hazards, near misses and incident reporting requirements that apply to the Alliance Pipeline system, including how these are reported to external stakeholders. The practice has a number of objectives with a few key examples as follows:

  • Allows hazards to be identified in the workplace so that they can be effectively controlled and communicated; and
  • Creates a risk-aware culture in which Employee-Partners and contractors “find and fix”; that is, they are able to recognize hazards and incidents when they occur or have the potential to occur, and work to expedite the remediation process.

While Alliance has established and implemented a documented practice, this document 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 to this, Alliance has developed an internal document hierarchy which includes when a process (among 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 been used consistently in the organization.

Summary

The Board found that Alliance had established and was maintaining a data management system for monitoring and analyzing the trends in its hazards, incidents, and near-misses.

The Board also found that Alliance has not established and implemented a management system and Emergency Management program 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.

Based on the Board’s evaluation of Alliance’s management system and Emergency Management 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

4.3 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:

OPR section 6.5(1)(w)(x)

Assessment:

Management System and Emergency Management Program Quality Assurance Program

During the audit, Alliance pointed to their Accountable Officer Report Process and to the activities listed within the Annual Accountable Officer Report as evidence to demonstrate it has established and implemented a quality assurance program for its management system and Emergency Management program. The Board has found, however, that Alliance’s interpretation of a Quality Assurance Program is incorrect. The Board has provided clear guidance as part of the guidance notes that accompany the OPR that a program is not simply a description of activities. Programs are: “a documented set of processes and procedures designed to regularly accomplish a result. A program outlines how plans, processes and procedures are linked, and how each one contributes toward the result. Program planning and evaluation are conducted regularly to check that the program is achieving intended results.” The Board’s definition is included in Section 1.0 Audit Terminology and Definitions of the attached audit report.

The Board notes that while a management system and Emergency Management program deficiency currently exists, the Board did verify that quality assurance activities are occurring at the management system and Emergency Management program level.

Management System Audit Process

At the time of the audit, the process of conducting audits in accordance with section 53 and for taking corrective and preventive actions if deficiencies are identified was being completed at the various protection program levels and not by an established and implemented management system process as required by OPR, section 6.5(1)(w). Alliance did demonstrate through its revised ORMS framework that it is in the process of developing an audit process.

Emergency Management Program Audit Process

At the Emergency Management program level, Alliance has referenced a HSMS established practice to give an objective review of the design and effectiveness to verify that it is effectively implemented, maintained and that it follows documented policies, program, practices, and procedures. Included in this practice is a section on completing audits.

As part of Alliance’s demonstration, Alliance provided the results of its external Certificate of Recognition (COR) audits that occurred in 2004 and 2008 respectively and the results from a comparison to the Canadian Energy Pipeline Association Integrity First Emergency Management Guidance Document. The Board notes that while these audits and comparison could assess some of Alliance’s legal requirements as they pertain to the Emergency Management program, it would not account for all of the legal requirements as required in OPR, section 53. Finally, the Board notes that OPR, section 53 has a requirement to audit on a three year basis. As Alliance last conducted an audit in 2008, this frequency requirement has not been met.

While Alliance has established and implemented a documented practice, this document 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 to this, Alliance has developed an internal document hierarchy which includes when a process (among other type of documents) should be developed and how it is defined. The Board reviewed this definition and determined that it does align with the Board expectations; however, it is not been used consistently in the organization.

Summary

The Board found that Alliance was undertaking many of the activities that are normally associated with a quality assurance program. The Board found, however, that Alliance had not organized them within a program as required by the OPR.

The Board also found that Alliance has not established and implemented a documented management system and Emergency Management program process for conducting audits in accordance with section 53 of the OPR.

The Board found that Alliance was not able to demonstrate that it has undertaken audits consistent with OPR sections 53 requirements.

Based on the Board’s evaluation of Alliance’s management system and Emergency Management 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:

OPR section 6.5(1)(p)

Assessment:

Management System and Emergency Management Program Records Management Process

To demonstrate its compliance with OPR section 6.5(1)(p), 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 among 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 management system and Emergency Management program process deficiency, Alliance was able to demonstrate that records documenting the implementation of the Emergency Management program were being generated, retained and maintained. Examples provided to the Board included records verifying training, safety meetings, and the completion of job observations.

Summary

The Board found that Alliance had implemented consistent records management practices to document the implementation of its management system and Emergency Management program.

The Board also found that Alliance has not established and implemented a management system and Emergency Management process that meets the OPR requirements.

Based on the Board’s evaluation of Alliance’s Management System and Emergency Management 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:

OPR section 6.5(1)(w)(x), 6.6

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 Emergency Management Program Process

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

  • Accountable Officer Report Process;
  • Operational Excellence Management System – OEMS Management Review Process;
  • HSMS Internal Process Assessment Practice; and
  • Health, Safety and Environment Management Committee (HSEMC) meetings.

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 was implemented by practice in order to prepare the 2014 Annual Accountable Officer Report;
    • The design of the process meets the Board’s working definition as it includes the Board’s common 5 w’s and h approach (who, what, where, when, why and how);
    • Process does account for a review of the management system and Emergency Management 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 Board’s common 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.
  • HSMS Internal Process Assessment Practice
    • As prescribed, this practice is intended to be a conformance check to ensure that HSMS processes are being followed;
    • The practice also states this assessment is to be conducted at a minimum of once every three years and thus does not ensure that these reviews are completed annually as required by the OPR;
    • This practice 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 developed an internal document hierarchy, which includes when a process (among 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.
  • HSMEC Committee Meetings
    • Records provided to the Board from 2013 to date have demonstrated that these meetings have occurred quarterly;
    • The meetings include a review of incidents, performance of goals, objectives and targets as well as staff resourcing; and
    • This activity is not integrated by process to either the Accountable Officer Report Process and OEMS Management Review Process referred to above.

In summary, the Board notes that Alliance is conducting several activities to review its management system and Emergency Management program. However, these activities are not integrated and thus do not meet the Board’s management system and Emergency Management program process requirements. Alliance will have to develop corrective actions to address the described deficiencies.

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 was 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 Board’s common 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 Emergency Management 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 managements;
  • 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 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 management system and Emergency Management 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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