ARCHIVED - Maritimes and Northeast Pipeline Management Ltd. - Audit Report OF-Surv-OpAud-M124 01 - Appendix IV: M&NP Emergency Preparedness and Response Program Audit Evaluation Table

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Appendix IV:
M&NP Emergency Preparedness and Response Program Audit Evaluation Table

1.0 POLICY AND COMMITMENT

1.1 Policy and Commitment Statements

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

References:[1]
OPR-99 sections 4, 47 and 48
CSA Z662-07 Clause 10.2.2

Assessment:
M&NP’s Operator demonstrated that it has an Emergency Management (EM) policy in place that is well communicated throughout the company. Interviews conducted with Field Technicians, the District Manager and Lands and Public Awareness Coordinators (Coordinators) verified that all are well aware of the EM policy. They noted that the policy is reinforced at least annually and that management is open and accessible for direct feedback on policy matters from all levels of the company. The EM policy is contained within a document titled: Maritimes and Northeast Pipeline Emergency Preparedness and Response Program updated May 2010.

Interviews with Field Technicians, the District Manager, the Area Manager and Coordinators verified that management is committed to and fully supports the Emergency Preparedness and Response (EPR) Program. Monthly safety meetings allow all staff to raise issues and provide management feedback, and upward feedback and involvement is encouraged. Feedback and action items are recorded at every meeting to ensure they are addressed and tracked. The Field Technicians are also very involved with the Standard Operating Procedure (SOP) harmonization project. Management has provided the budget to support the EPR Program including the cost of conducting exercises and purchasing new equipment as required. Personnel interviewed indicated that there has been no lack of budget support for the EM programs.

Based on interviews and documents reviewed, the Board verified that the Operator has formally endorsed its EPR Policy and that the commitment to managing its hazards and risks is evident at all levels within the organization.

Compliance Status: Compliant

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

2.0 PLANNING

2.1 Hazards Identification, Risk Assessment and Control[2]

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

References:
OPR-99 sections 4(2), 37, 39, 40, 47, 48
CSA Z662-07 Clauses 10.2, 10.3.2

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

In the design phase of each pipeline in the M&NP system, the Operator conducts thermal radiation simulations to determine the appropriate emergency planning zones (EPZs) for the pipeline. The EPR Program summarizes the EPZ for each pipeline in the M&NP system and the Emergency Response Plan (ERP) establishes response procedures for emergencies within the EPZs. On an annual basis, the Operator holds an EPR meeting of the Area Managers, District Managers and Coordinators for the purposes of reviewing EPR matters and for planning EPR activities. The EPZs form the basis for design of the ERP. A review of the existing hazards and appropriateness of the EPZs for each of the M&NP pipelines is on the agenda for this annual meeting. If any pipeline operating parameters change, the Operator recalculates the EPZ.

The Operator’s personnel described the process for annual review of hazards and risks. Minutes of the annual meeting confirmed that a risk assessment was conducted in terms of operational changes and the potential changes to pipeline EPZs and training. The Operator described the Encana Deep Panuke project as an example. The Deep Panuke project would deliver sour gas to the Goldborough gas plant where it would be sweetened before transmission on the M&NP mainline. The potential exists for a process upset at Goldborough that would result in sour gas being released into the M&NP mainline. This hazard was assessed and it was determined that H2S training would be provided to appropriate technicians. Following the review of the minutes of the annual meeting, the Board could not confirm that there was a process in place to conduct a periodic review of existing hazards or to identify and incorporate new ones.

The Environment Health and Safety (EHS) Management System (MS) Performance Standard 2.0 EHS Risk Management sets out the procedure for identifying hazards, assessing hazards, determining levels of risk posed by the hazards and controls to mitigate the risks. The performance standard identifies a wide range of environment, health and safety hazards that could pose risks to people and environmental end points. An Operational Controls Table is used to maintain an inventory of this information according to activity, identified hazard, assessment of risk, reference to legal requirements and established controls.

Procedures were developed based on the requirements set out in Performance Standard 2.0 for assessing the primary hazards posed by the M&NP pipeline system, such as conducting thermal radiation simulations in order to determine the EPZs, and conducting an annual review of the hazards and risks. However, it could not be verified that these procedures met the intent of this Performance Standard in that all possible hazards to the public, responders, property and the environment had been identified, and that the level of risk posed by each hazard, the risk ranking and appropriate control measures for the purpose of emergency response planning had been determined.

It could not be demonstrated that the Operator has appropriately implemented its process for identifying hazards and determining appropriate control measures for emergency response planning.

Compliance Status: Non-compliant

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

2.2 Legal Requirements

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

References:
OPR-99 sections 4, 6, 32, 40, 47 and 48
CSA Z662-07 Clause 10.2.2(g)

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

The EPR Program includes a process to identify and integrate legal requirements. The applicable sections of the OPR-99 related to EM are integrated into the EPR program. The Operator updates the ERP on an annual basis and files copies of the updates with the NEB in accordance with its document control procedures. The ERP identifies National Energy Board (NEB or the Board) incident reporting requirements in accordance with the OPR-99 requirements.

The Manager of Regulatory Affairs described the process that is in place to monitor regulatory changes. The governing legislation, regulations, standards, advisories and other applicable regulatory information is tracked, any changes or updates undergo strategic analysis to identify business impacts and required operational changes and then action plans are developed and implemented. All regulatory changes are captured and an annual summary of regulatory changes is broadly distributed throughout the company. Examples of changes being tracked are the proposed damage prevention regulations and the NEB pipeline abandonment initiatives.

Both M&NP and the Operator were able to demonstrate through interviews and documents reviewed that they had a process to identify and integrate legal requirements into the EPR Program.

Compliance Status: Compliant

2.3 Goals, Objectives and Targets

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

References:
OPR-99 sections 40, 47 and 48
CSA-Z662-07 Clause 10.2.2(h)(ii)

Assessment:
The EHS MS Performance Standard EHS Objectives Targets and Strategies 7.1 sets out the goals, objectives and targets relevant to the risks and hazards associated with the facilities and activities. It was verified that the Operator was in compliance with this element through the audits of the Environment and Safety Programs. For more information as it relates to this program element refer to Appendix II: M&NP Safety Program Audit Evaluation Table and Appendix III: M&NP Environmental Protection Program Evaluation Table.

Compliance Status: Compliant

3.0 IMPLEMENTATION

3.1 Organizational Structure, Roles and Responsibilities

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

References:
OPR-99 sections 40, 47, 48
CSA-Z662-07 Clauses 10.2.2(b), 10.3.2.4

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

Based on its organizational structure, the Operator has assigned company personnel roles and responsibilities within the program. The Operator tests the adequacy and effectiveness of EPR roles on an annual basis through full scale mock exercises and table top exercises. Interviews with the personnel verified understanding of roles and responsibilities. Review of related documentation confirmed that the Operator has the capability to respond to an emergency based on the training received by personnel, the results of exercises conducted and the training of mutual aid partners who participate in emergency response exercises.

The Operator was able to demonstrate that it has developed roles and responsibilities within its organizational structure to effectively implement its EPR Program.

Compliance Status: Compliant

3.2 Management of Change

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

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

References:
OPR-99 section 6
CSA-Z662-07 Clause 10.2.2 (g)

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

The EHS MS Management of Change Performance Standard 2.7 sets out the expectations of operating companies for management of change (MOC). For the EPR Program, the Operator reviews and updates its program on an annual basis, including an assessment of changes that may affect the program. Inputs are received from the results of emergency response exercises, continuing education and liaison programs, and any changes to operating conditions of the pipelines. Updating includes ongoing maintenance of the landowner database. Inputs to the landowner database include information received in response to the annual letter to all landowners along the M&NP system, GIS data from the provinces, data from the provincial Emergency Measures Organization (EMO), 2008 City of Halifax data, City of Saint John data and title searches as required. The landowner database is incorporated into the Emergency Response Mapping.

Despite the documented processes in place to monitor changes directly related to the EPR Program, the Board could not confirm that the Operator had a documented and implemented MOC program that encompassed all operational programs. An overarching MOC process is required to identify, evaluate and integrate changes such as the introduction of new risks, hazards or legal requirements outside the EPR Program itself that could affect its implementation.

Compliance Status: Non-compliant

3.3 Training, Competence and Evaluation

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

References:
OPR-99 sections 28, 34, 35, 46 and 56
CSA Z662-07 Clauses 10.2.2(c), 10.3.2.4

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

The EHS MS Performance Standard 1.4 EHS Training establishes minimum expectations to ensure that appropriate training is identified and employees are properly trained. It also ensures that all employees have received required training at the appropriate frequency and that the completed training is tracked.

The EPR Program identifies the training program for operations staff related to the field ERP. The training program sets out that training will encompass, at a minimum:

  • formal group and individual review of the emergency response plan and sign-off by the employee completing the review;
  • tabletop or communications exercises;
  • critique of the ERPs; and
  • completion of any identified deficient training related to the use of response equipment.

The training will be complemented by:

  • attendance at related conferences and workshops;
  • incident command training;
  • media relations; and
  • crisis communication training.

Operator staff informs visitors to company maintenance sites of the practices and procedures to be followed. At each office or field location visited, the auditors were signed-in to the site, given a site orientation, and informed of the safety and emergency procedures to be followed in the event of an emergency.

Interviews verified that all personnel who have an emergency response role receive appropriate levels of training for their respective roles in accordance with the EHS MS Performance Standard 1.4 EHS Training and the EPR Program. In addition, all field technicians and other personnel receive core safety training. While the field technicians are not provided specific emergency management training such as Incident Command System or Emergency Site Management, they receive training in company emergency response procedures, as well as plan and participate in several emergency response exercises per year, including at least six table top exercises and one full scale mock emergency exercise. Company personnel rotate through exercise roles such as incident commander, on-site supervisor, safety officer and liaison officer in order that training and response capability are maximized. In addition to participating in exercises, the Coordinators and district and area managers receive additional training in incident command and emergency operations centre management from both the Nova Scotia and New Brunswick EMO. Upon completion of this training, company employees complete written examinations. Examination of training records for field technicians verified participation in emergency response exercises. The hard copy training records of all employees are filed and tracked by administrative staff and training requirements are managed by the Learning Management System (LMS) that tracks training completion and generates an e-mail to the employee and his or her manager when training is due. Field technicians noted that, although there is not a field operator qualification procedure in place for M&NP, the company is developing a field operator qualification procedure.

A field technician described the response taken to a cargo plane crash at the Halifax Airport, and credits the skills gained from company exercises with the success in dealing this real emergency.

Through the Operator’s continuing education and liaison program, first responders such as fire departments, police and emergency health services, the New Brunswick and Nova Scotia EMOs, pre-qualified contractors, the public, and other persons who may be involved in an emergency on the M&NP system receive training as required for their respective roles. Documents reviewed verified that the continuing education forums and emergency response exercises are very well attended by all of these groups, and that the forums and exercises are conducted several times per year according to a well planned and managed schedule. All participants sign-in to the exercises and participation is tracked. The most recent full scale mock exercise conducted by the Operator involved almost 70 participants.

Based on interviews and documents reviewed, the Operator demonstrated that personnel receive adequate training in emergency response.

Compliance Status: Compliant

3.4 Communication

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

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

References:
OPR-99 sections 28, 29,33, 34, 35
CSA Z662-07 Clauses 10.2.2(d), 10.3.2.2, 10.3.2.3

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

The Operator has a documented continuing education and liaison program in place to educate the public, first responders and contractors that may have a role during an emergency on the M&NP pipeline. Document review verified the content of information provided to stakeholders, including information on pipeline safety, emergency preparedness, what to do if there is a suspected pipeline emergency and company contact information. Communication tools include the mailing of annual information letters to all residents within the EPZs and, where requested, meetings with residents to discuss the information brochures; First Responder booklets; presentations to first responders, forestry operators, landowners and municipalities; video presentations; personal visits to landowners; and public awareness presentations. The Board also reviewed the Public Awareness binders where activities and schedules of engagement events are tracked.

Communications under the Operator’s public relations and awareness program are targeted to:

  • EPZ residents;
  • Schools - including a natural gas education program;
  • Fire departments, police, EMOs and emergency health service;
  • Communities and interest groups;
  • Forestry operators;
  • Municipal, provincial and federal government; and
  • Contractors.

The Operator also has a documented Public Awareness Plan to address the requirements of the Board’s Pipeline Crossing Regulations and the respective section of the OPR-99. The Public Awareness Plan serves as a formal communication guide and schedule to educate the public and others of the responsibilities of working or living near the pipeline. The Public Awareness Program evaluation is Appendix VI of this report.

Accu-link call system is a 24-hour call system reached through a 1-800 number that is on the M&NP signs and website. The Accu-link centre will manage any call received by the Operator for any reason. In the event of a phone call to report a potential pipeline emergency, the Accu-link centre records essential information on the nature of the emergency, caller contact information, location of the caller and location of the potential emergency. The call is immediately referred to the Operator’s on-call duty officer and an electronic ticket is generated. The Accu-link system also receives calls related to line locate requests and work proposed on the M&NP Right-of-Way (RoW). For any work proposed within 500 meters of the RoW the caller is referred to the Operator for review and approval of the work. The call system was tested as part of the audit during non-business hours which confirmed the system worked well. The Operator was able to demonstrate that it has communication processes to inform all persons associated with its facilities and activities of its EPR Program.

Although there are several internal and external mechanisms in place for communicating EPR Program related information, the Operator could not demonstrate that there is a formalized and implemented communication plan that outlines the distribution of various types of information to appropriate parties. While interviews confirmed communication is occurring throughout technical networks and through the means identified above, without a formal communication plan, the Operator cannot ensure that all stakeholders and interested parties are receiving the appropriate information in a timely fashion.

The Operator was able to demonstrate that it has adequate communication processes regarding EPR Program information. The Board recommends that information related to the third party activities be included in a formalized communication plan.

Compliance Status: Compliant with Recommendation

3.5 Documentation and Document Control

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

References:
OPR-99 sections 27 and 32
CSA-Z662 Clause 10.2.2(e), (f), 10.3.1.1(d)

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

The EPR Program Manual describes the elements of the EM program. The EPR Program Manual is reviewed and revised as necessary through the annual management review process. Documents such as the ERP Manual and emergency response mapping are also controlled and distributed to appropriate agencies and First Responders that may have a role in an emergency. Urban and rural fire departments have copies of the emergency response mapping for their respective regions receive updates as required through the document control process. The provincial fire marshals and the Saint John Fire Department hold controlled copies of M&NP’s ERP.

The EPR Program includes elements such as: risk assessment, liaison program, continuing education program, emergency preparedness manuals, training, validation, document control, policy, goals and program review.

The Field ERP sets out the company response procedures in the event of a pipeline emergency on the M&NP system in New Brunswick and Nova Scotia. The document is current to February 2007 and in accordance with the EPR Program, it undergoes management review on an annual basis. Review of the minutes of the annual meeting confirmed that the ERP is a standing agenda item for the annual review. The ERP contains the appropriate sections and content to enable the Operator to deal with an emergency, including but not limited to: levels of alert; response team structure; mutual aid; command posts; initial action and notification; flowcharts; role descriptions; responder safety; EPZ isolation; public safety; ignition guidelines; government roles; post incident procedures; maps; forms; training; and exercises, etc.

Interviews and site visits verified that all field vehicles and offices have updated copies of the ERP Manual. It is a living document that is controlled and used regularly for exercises and training.

Compliance Status: Compliant

3.6 Operational Control - Normal Operations

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

References:
OPR-99 sections 27-49
CSA Z662-07 Clauses 10.2.2(f), 10.3.1

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

As part of an O&M Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EPR Program. The EPR Program establishes and maintains the processes to develop, implement, and communicate mitigative, preventive and protective measures to address the risks and hazards posed by the M&NP system. Through its continuing education, liaison and public awareness programs the Operator has established processes to communicate the mitigative, preventive and protective measures.

Compliance Status: Compliant

3.7 Operational Control - Upset or Abnormal Operating Conditions

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

References:
OPR-99 sections 32, 35 and 52
CSA-Z662-07 Clause 10.3.2

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

The Operator has an ERP in place for the operation of the M&NP pipeline systems in New Brunswick and Nova Scotia. The ERP includes appropriate roles, equipment, procedures, etc. for the hazards identified. The ERP Manual is updated annually, with version and distribution control processes applied and followed. The ERP Manual and any updates are filed with NEB.

The Operator conducts full scale mock and table top exercises on a scheduled basis to train company personnel and test first responders and contractors. The Operator regularly informs the public, agencies and first responders (fire departments, police and Emergency Health Services) about the locations of its pipelines and facilities, the hazards associated with its pipeline system, the procedures to follow in the event of an emergency, and the names and contact numbers of the company in order to report any suspected or actual pipeline emergency.

The Operator has a documented incident reporting procedure and conducts debriefing sessions upon completion of exercises in order to review and learn, and revise the EPR Program as required.

Compliance Status: Compliant

4.0 CHECKING AND CORRECTIVE ACTION

4.1 Inspection, Measurement and Monitoring

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

References:
OPR-99 sections 36, 39, 47, 48, and 53(1)
CSA Z662-07 Clauses 10.2.2, 10.3.2.4, 10.14.1

Assessment:
Surveillance and monitoring are documented under the Integrity Management Program (Appendix I), Safety Program (Appendix II), Environmental Protection Program (Appendix III), Crossings Program (appendix V) and Public Awareness Program (Appendix VI).

Compliance Status: N/A

4.2 Corrective and Preventive Actions

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

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

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

References:
OPR-99 sections 6 and 52
CSA-Z662 Clauses 10.2.2(g) and (h)

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

The EHS MS Incident Learning and Prevention Performance Standard 8.1 sets out the detailed incident investigation procedures. Document review confirmed that the Operator has standard guidelines for incident reporting that addresses the requirements of OPR-99 section 52. The ERP also includes a post incident evaluation process.

The Operator conducts several exercises per year including table top and full scale mock exercises. There is documentation that supports the planning and implementation phases of the exercises. However, documentation is absent that shows the feedback received from participants in the exercises, the lessons learned from the exercises and the actions put in place to address suggested improvements and for incorporating feedback into the EPR Program. There is no documentation demonstrating that the Operator tracks and verifies completion of the actions.

The Operator did not demonstrate that it has a process for tracking, assigning actions and verifying completion of actions from the lessons learned in its table top and full scale emergency response exercises and therefore does not have procedures in place to identify opportunities for improvement in its protection programs and procedures.

Compliance Status: Non-compliant

4.3 Records Management

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

References:
OPR-99 sections 32, 47, 48, 52, and 56
CSA-Z662-07 Clause 10.2.2(e)

Assessment:
As part of an O&M Agreement between M&NP and its Operator, the Operator is implementing and maintaining the EPR Program and all associated processes including the maintenance of records. Interviews and document review verified that all training records, monthly inspection reports, budgets, compliance reports, manuals and other documents are managed and tracked through programs such as System and Integrity Logging, the LMS and the web portal.

The Operator was able to demonstrate that it has a records management program for the EPR Program that meets requirements.

Compliance Status: Compliant

4.4 Internal Audit

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

References:
OPR-99 sections 53 and 55
CSA Z662-07 Clause 10.2.2(c) and (h)(iii)

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

The EHS MS Performance Standard 9.1- EHS Audits sets out the expectations for an internal audit program. The Board verified that the program audits against the requirements of OPR-99 as it relates to EM.

The Operator was able to demonstrate that it has an audit program that includes the EPR Program.

Compliance Status: Compliant

5.0 MANAGEMENT REVIEW

5.1 Management Review

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

References:
OPR-99 section 55
CSA Z662-07 Clause 10.2.2(h)(iii)

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

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

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