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

Appendix II
Spectra Energy Management Inc. as General partner
and Agent for Spectra Energy Empress L.P. (SET-PTC)
Safety Program Audit Evaluation Table

Table of Contents

• 1.0 Policy and Commitment
  • 1.1 Policy and Commitment Statements
• 2.0 Planning
  • 2.1 Hazard Identification, Risk Assessment and Control
  • 2.2 Legal Requirements
  • 2.3 Goals, Objectives and Targets
• 3.0 Implementation
  • 3.1 Organizational Structure, Roles and Responsibilities
  • 3.2 Management of Change
  • 3.3 Training, Competence and Evaluation
  • 3.4 Communication
  • 3.5 Documentation and Document Control
  • 3.6 Operational Control-Normal Operations
  • 3.7 Operational Control-Upset or Abnormal Operating Conditions
• 4.0 Checking and Corrective Action
  • 4.1 Inspection, Measurement and Monitoring
  • 4.2 Corrective and Preventive Actions
  • 4.3 Records Management
  • 4.4 Internal Audit
• 5.0 Management Review

1.0 POLICY AND COMMITMENT

1.1 Policy and Commitment Statements

Expectations:

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

References:^{Footnote 1}

OPR-99 Sections 4 & 47
Canadian Standards Association Z662-11 Clause 3.1.2(a)
Canada Labour Code (CLC) Part II, Sections 125(1)(d)(i)-(ii),125(1)(z.09)

Assessment:

1. SET-PTC has an Environment, Health and Safety (EHS) Policy which has been approved and adopted by Spectra Energy Transmission’s president and chief executive officer. The EHS Policy serves as the foundation for all EHS SET-PTC activities by establishing a clear vision of EHS performance shared by Spectra Energy Transmission (SET). The EHS Policy has been defined by senior management to demonstrate SET-PTC’s commitment to the protection of the environment, and the health and safety of its employees.

The EHS Policy is applicable throughout SET-PTC’s EHS Management System (MS), which has been designed and implemented to ensure the five principles of the EHS Policy (Accountability, Stewardship, Standards, Performance and Communication) are achieved on a day-to-day basis.

Compliance Status: Compliant

2.0 PLANNING

2.1 Hazards Identification, Risk Assessment and Control^{Footnote 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) & 47
CSA Z662-11 Clauses 3.1 and 3.1.2
CLC Part II Sections125.(1)(s)(z.03)-(z.05), 125(1)(z.13)-(z.16)
Canada Occupational Health and Safety Regulations, SOR/86-304, (COHSR) Sections19.1(1), 19.3(1)-(2), 19.5(1)-(5)

Assessment:

The SET-PTC EHS MS includes a Hazard Management Program (HMP) which includes an Occupational Exposure Management Program as well as a task hazard analysis mechanism. The HMP also includes the development of a Critical Task Analysis Risk Evaluation Tool, a Workplace Exposure Assessment and Control Lists.

The HMP involves characterizing and ranking the relative risk of worker and/or company hazards for all SET-PTC Similar Exposure Groups (SEG). SEGs are groups of workers that have the same general exposure profiles because of the similarity and frequency of the tasks they perform, the materials and processes with which they work, and the similarity in the way they perform the tasks. SEGs are broken down by: (1) operating area; (2) job description; and (3) job tasks (including job tasks that utilize contractors).

A SET-PTC standard is in place for each critical practice (e.g., working at heights, lockout/tag out, ground disturbances, confined space and sour work). The SET-PTC Critical Practice Standards are reviewed by SET-PTC’s Health and Safety Department every three years to ensure supervisors and workers receive relevant job-specific training. According to SET-PTC staff, the goal of Critical Practice Standards is to allow staff to develop the ability and skill to see beyond the usual concerns of any given task into possible side effects and consequences. SET-PTC has integrated this program training requirement for each critical practice along with recommended training tracked in SET-PTC’s Learning Management System (LMS).

SET-PTC has a developed a Self-Assessment Program. This program includes an updated inspection form available on the SET-PTC intranet website which directs the SET-PTC employee to assess area conditions rather than assess specific hazards. A corrective action plan is also included with the updated inspection form. Local area management delivered presentations on the program and updated EHS inspection forms.

SET-PTC has developed and implemented a Violence Prevention in the Workplace Policy and Program. SET-PTC employees receive Violence Prevention In the Workplace as well as EHS training when they are first hired and annually thereafter.

SET-PTC has implemented the Operational Steering Committee (OSC) Technical Risk Watch Report at the Operations Steering Committee and Area level. The objectives of the OSC Technical Risk Watch Report are to identify and manage technical risk, including:

• personal safety;
• process safety;
• reliability; and
• regulatory.

The goal is zero loss incidents, and to demonstrate mindful leadership principles of knowing, and managing risks to SET-PTC operations.

SET-PTC has initiated the Major Incidents Corrective Actions (MICA) Project, which will review all formalized functions that are implemented and being followed at SET-PTC. The MICA Project’s objective is to standardize the following:

• job safety analysis ;
• planning;
• safe work practices;
• PPE; and
• safe work permits.

Subject matter experts from all SET-PTC business units have been resourced to support the MICA project. Also, the "Driven to be Safe" project has been initiated to standardize the defensive driving program throughout SET-PTC/PTC Pipeline operations.

SET-PTC’s Contractor EHS Management Standard provides guidance for the registration, selection and oversight of all contractors performing work for SET-PTC. SET-PTC contracts ISNetworld (ISN) to manage contractor pre-qualification. SET-PTC has developed criteria for the pre-screening of contractors. The information requested from each contractor is used to evaluate general safety abilities. Safety information collected includes a contractor’s Total Injury Frequency Rate, company Health and Safety Manual, safety citations from a regulatory body, as well as Worker’s Compensation Board (WCB) rate sheets and WCB clearance letters. The contractor safety manuals are reviewed by a third party, to help eliminate the perception of bias. ISN is not used to determine contractor training competency. Upon completion of the contract, the contractor's performance is reviewed and documented.

Based on documents reviewed and interviews with operation staff, SET-PTC was able to demonstrate it was in compliance with the requirements of sub-element 2.1 Hazard Identification, Risk Assessment and Control.

Compliance Status: Compliant

2.2 Legal Requirements

Expectations:

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

References:

OPR-99 Sections 4, 6 and 47
CSA Z662-11 Clause 3.1.1
CLC Part II Section 125(1)(v)
COHSR Section 19.1(1)

Assessment:

SET-PTC’s EHS Regulatory Change Monitoring Process, for health and safety regulation changes, was implemented 29 September 2009. SET-PTC contracts Templegate Information Services Inc. and Cyber Regs, subscription services for tracking legal initiatives and recent legal decisions (e.g., federal and provincial environmental initiatives, federal and provincial Occupational Health and Safety (OHS) initiatives, international initiatives, standards initiatives, other legal initiatives and recent legal decisions).

The SET-PTC EHS MS Manual requires the review and evaluation of contractor health and safety work and communication plans developed in advance of work, to ensure they are appropriate to the risks of the work, and ensure functional area integration for federal and provincial OHS requirements to ensure conflicts do not exist. A review of SET-PTC safety training is required to ensure that federal legislative obligations are reflected in all safety training, and that identified conflicts are eliminated. The audit also found that the OPR, CLC and COHSR are not listed or referenced in the EHS Manuals.

The Scorecards are used to record voluntary regulatory instruments (Assurances of Voluntary Compliance or AVCs). However, it was noted that the Board Inspection Order (September 2012) was not recorded in the Scorecards.

Additionally, SET-PTC has not fulfilled its legal requirements set out in OPR.

Based on the deficiencies identified, the Board was unable to verify the EHS Regulatory Change Monitoring Process as an adequate mechanism to identify, integrate legal requirements into its EHS MS and resolve non-compliances as they relate to legal requirements.

Compliance Status: Non-Compliant

2.3 Goals, Objectives and Targets

Expectations:

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

References:

OPR-99 Section 47
CSA Z662-11 Clause 3.1.2(h) (ii)
COHSR Section 19.1(1)

Assessment:

Goals are tangible objectives for meeting SET-PTC EHS Policy and principles. The goals represent a shift from identifying EHS hazards to improving overall EHS performance by continually setting and reaching targets. Each member of SET-PTC’s leadership, at a level of Director or above, develops and implements an annual personal Safety Action Plan. Formal staff goals for Active EHS Leadership (Leadership Safety Action Plans), which include: People Oriented Culture (Employee Recordable Injury Frequency, Employee Vehicle Incident Reporting and Contractor Recordable Injury Frequency); Physical Environment (Non-Recordable Incident Reporting and Recordable Incident Corrective Actions); and Environmental Impacts (Reportable Spills), are set to a yearly and a multi-year plan within the Spectra Energy (SET-PTC) EHS Blended Scorecard, an internal document used to determine individual goals and targets. SET-PTC’s ‘Zero Incident Culture’ assigns incident reporting responsibility to all SET-PTC employees and contractors.

Employees discuss objectives with their supervisor at the beginning of the year, at least once during the year, and again at the end of the year when the past year’s performance is evaluated and objectives are established for the next year. Safety goals, targets and objectives have been identified for all staff and are included in individual job descriptions. Safety performance is included in the overall employee objectives and employees are provided recognition in meeting EHS performance objectives through a program known as Short Term Incentive Pay (STIP). The Accountability Management System and Performance Management goals and objectives are reviewed three times per year. STIP is linked to recorded injuries, vehicle incidents, contractor recordable incidents and environmental spills (considered a failure of process safety). Senior Management may not be eligible for Long Term Incentive Pay if targets are not met.

SET-PTC staff demonstrated there are formalized processes in place ensuring that safety performance was being regularly and formally reviewed, and revised on an on-going basis.

Based on documents reviewed and interviews with operation staff, SET-PTC was able to demonstrate it was in compliance with the requirements of sub-element 2.3 Goals, Objectives and Targets.

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 Section 47
CSA Z662-11 Clauses 3.1.1 and 3.1.2(b)
CLC Part II Sections 125(1), 125.1, 126, 134.1, 135(1), 135.1, 136 and 137

Assessment:

The SET-PTC Roles and Responsibilities Performance Standard 1.2 establishes the expectations for demonstrating management’s commitment and support to ensure the effective implementation of the EHS MS and improvement of EHS performance.

Formal documentation for EHS roles, responsibilities and accountabilities for management, departments, employees and contractors includes: programs and procedures; job position descriptions; organization charts; roles; responsibilities; and authority matrices.

SET-PTC indicated that a formal organization review of the EHS & Operations Services groups was completed in 2012. This review did result in realigning the EHS from the Vice President (VP) Operations to a new VP of EHS & Risk Strategy. The Board views this as an improvement in the organizational structure as it will promote better oversight, improve impartiality and remove local influence in decision making and reporting of issues. However, review of the documentation provided on this organizational review indicated that this review was focused on the appropriate management structure, and did not consider whether there were adequate resources for SET-PTC’s EHS to effectively function.

Compliance Status: Non-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 Z662-11 Clause 3.1.2(g)
CLC Part II Sections 125(1), 125(1) (z.05)-(z.06)
COHSR Sections 19.5(4), 19.6(2)

Assessment:

The Board verified that a Management of Change (MOC) Program is in place which outlines the process for identifying, assessing and implementing procedural changes once they have been approved by the accountable individual (EHS MS Management of Change Performance Standard 2.7). There is also a collaborative process in place to review all Standard Operating Procedures against all regulatory requirements and best practices for all of SET-PTC. EHS is leading the process with the support of Senior Management and Regional subject matter experts.

SET-PTC demonstrated that it has a formal process and dedicated staff for managing changes to its assets. However, SET-PTC’s MOC process, as demonstrated, is not considered compliant as it applies only to physical (asset) changes and not to changes required in practices or procedures that could result from:

• changes to legal requirements;
• the identification of new hazards; or
• results of monitoring, inspections or investigations.

Further, SET-PTC’s MOC process only manages changes on a reactive basis (i.e., changes once the need has been identified). The Board expectation is that company MOC processes be proactive and formally linked to processes for the identification of changes that could affect the management and protection programs (e.g., Integrity Management, Safety, Environmental Protection, Emergency Management Programs, etc.).

SET-PTC has initiated a MOC Program review. December 2013 is the scheduled implementation of the revised MOC Program. As the MOC review is incomplete, the Board was unable to evaluate the results of the MOC review, relative to the deficiencies identified above Accordingly, the Board was unable to verify that a fully-implemented MOC program was in place to identify, document and analyze changes that could affect the EHS MS, including introduction of new risks, hazards or legal requirements.

Compliance Status: Non-Compliant

3.3 Training, Competence and Evaluation

Expectations:

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

References:

OPR-99 Sections 18, 28, 29 & 47
CSA Z662-11 Clause 3.1
CLC Part II Sections 122.3, 125(1)(d)-(f), 125(1)(s), 125(1)(z.03)-(z.11), 125(1)(z.14)-(z.15), 125(1)(z.17)-(z.19)

Assessment:

SET-PTC’s Performance Standard establishes the minimum expectations to ensure that:

• appropriate training is identified for all employees;
• employees are properly trained in, and understand, applicable EHS compliance standards, regulations, company policies and procedures, and best management practices; and
• employees perform their tasks, duties and responsibilities in a manner that protects the health and safety of SET-PTC employees, contractors, and the community.

SET-PTC’s Training Program Charter provides guidance and support to meet regulatory and business training expectations. Employee competency assessment in the application of skills is the responsibility of the employee’s leader or manager. The Accountability Management and Performance Management assessments determine employee competency and identify future training initiatives.

The SET-PTC Computer Based Training System contains a broad scope of safety based training modules and mechanisms.

Employee training records are stored in the LMS which generates monthly status reports for all leaders and groups, and annually assesses and communicates the status of the training programs and manuals. Employees are provided with any updates should additional training requirements be identified or should existing curriculums be changed. SET-PTC also supports its safety personnel to further their education and training to acquire and maintain Safety Professional Designations.

The SET-PTC’s Training Program Charter met the requirements of this sub-element, the Board has identified in sub-element 2.2 (Legal Requirements) of this appendix that a review of SET-PTC’s safety training is required to ensure federal legislation is reflected in the training and that identified conflicts are eliminated.

Compliance Status: Compliant

3.4 Communication

Expectations:

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

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

References:

OPR-99 Sections 28, 29, 30(b), 46, 47 and 56
CSA Z662-11 Clause 3.1.2(d)
CLC Part II Sections 124, 125(1)(q), 125(1)(s), 125(1)(z), 125(1)(z.01), 125(1)(z.03)
COSHR Sections 10.14, 11.5(2), 11.11, 12.10(1.1)(a)(ii), 12.10(1.2), 12.15, 13.11, 14.23, 17.6(1), 20.10, 19.1(1), 19.2(2), 19.6

Assessment:

SET-PTC was able to demonstrate that it employs many methods for communicating safety requirements with its internal and external stakeholders. Communication of safety information is done through safety stand down meetings; quarterly employee meetings and safety updates; daily tailgate meetings; daily and weekly safety reports; Health and Safety Newsletters; monthly safety and communication meetings; monthly reports to the EHS Corporate Group; contract management activities, pre-job meetings; its intranet sites; etc.

However, audit was unable to verify that the SET-PTC Internal and External Communication Performance Standard 6.0 (September 2006) is fully implemented thought out SET-PTC. Interviews of SET-PTC staff indicated that they were not always notified of received regulatory non-compliances (Board Inspection Order September 2012) that may impact on their operations. This lack of communication indicates that the Internal and External Communication Performance Standard is not consistently executed throughout SET-PTC.

The audit was unable to verify that SET-PTC meets the requirements of this sub-element and therefore have made a finding of Non-Compliant with respect to Communication.

Compliance Status: Non-Compliant

3.5 Documentation and Document Control

Expectations:

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

References:

OPR-99 Sections 27, 47 and 56
CSA Z662-11 Clauses 3.1.2(e),(f) and 10.5.1.1(d)
CLC Part II Sections 125(1)(z.03)-(z.06), 125(1)(z.09), 125.1(d)-(e), 125.1(f), 135.1(9)
COHSR Sections 1.5, 2.23, 4.6, 5.17, 5.18, 8.12, 8.14(4)-(7), 8.15, 10.3

Assessment:

To develop or revise an EHS standard, SET-PTC’s EHS Standard Development Committee reviews the following:

• EHS practices and procedures currently available within SET-PTC;
• legislation applicable to SET-PTC;
• CSA or other applicable industry standards;
• Spectra Energy or Spectra Energy Transmission Policies; and
• industry best practices.

Legal and Human Resources may be consulted as necessary during the development or revision of an EHS standard.

EHS Safety Specialists communicate draft standards to the OHSE Workplace Committees for review and comment in a timely manner. The EHS Standard Development Committee reviews all comments, updates the standards if necessary and provides feedback to individuals or committees who provided the input. The EHS Standard Development Committee develops an Implementation Impact Assessment for each proposed standard. Revised (updated) standards including comments from OHSE Workplace Committees and the Implementation Impact Assessment are sent to the EHS Director for review, comment, and communication to the Operations Management Team (OMT). Standards are endorsed by the OMT before review by the OHSE Oversight Committee. Proposed changes to EHS Standards are reviewed by the OHSE Oversight Committee to determine if consultation is required. New EHS Standards are approved by the EHS Director for implementation.

SET-PTC’s EHS Manuals do not reference OPR-99 requirements. Also, the audit found a number of performance standards and procedures that are either in draft status or out-of-date. For example:

• the Board requires that the On-Site SET-PTC Construction Manual be the same as the SET-PTC Construction Manual that is filed with the Board; and
• the Natural Occurring Radioactive Materials (NORM) Code of Practice indicates that it became effective on 22 October 1993 and that it was last reviewed 4 July 2008.

As the Board requires a regular review of all safety standards and procedures to ensure they are current and reflect revision dates, as well as all applicable requirements of the OPR-99, CLC Part II and COHSR, the Board finds SET-PTC to be non-compliant with respect to this sub-element.

Compliance Status: Non-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 Z662-11 Clauses 27 - 49
CLC Part II Sections 125(1), 125.1
COHSR Section 19.1(1)

Assessment:

The EHS MS contains procedures for identified work tasks typically encountered by SET-PTC personnel. The procedures reference industry standards and acknowledge compliance with applicable legislation.

Frontline supervisors review safe work permit practices with employees at operational and safety meetings. SET-PTC hazard assessment training for employees includes hazards and risks associated with tasks that are outlined in safe work permits.

It was confirmed in sub-element 2.1 of this appendix that critical task lists, risk assessment and job hazard analyses that have been completed include various mitigating measures that form the basis of the EHS MS procedures and which would ensure operational control is maintained. Therefore, the Board finds SET-PTC to be compliant with this sub-element.

Compliance Status: Compliant

3.7 Operational Control-Upset or Abnormal Operating Conditions

Expectations:

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

References:

OPR-99 Sections 32, 35 and 52
CSA Z662-11 Clauses 3.1, 3.2, and 10.5.2
CLC Part II Section 125(1)(o)
COHSR Sections 17.4, 17.5, 19.1(1)

Assessment:

The audit verified that SET-PTC has developed and implemented an emergency preparedness and response plan. Interviews and document review verified that personnel safety issues such as the emergency evacuation and muster locations are discussed during orientations and fire evacuation procedures are posted. Emergency evacuation drills and mock exercises are held on a regular basis.

SET-PTC staff participates in the Liquefied Petroleum Gas Emergency Responders Corporation (LPGERC). The LPGERC’s mission is to provide a level of service to participants that will encompass well trained and qualified people, quality equipment, knowledgeable advice and timely assistance to allow responders to deal effectively with a liquefied petroleum gas emergency.

Finally, safety issues are standard items on meeting agendas and are incorporated into ‘review and learn discussions’ for continual improvement purposes. Based on all of the foregoing, the Board finds SET-PTC to be compliant with this sub-element.

Compliance Status: Compliant

4.0 CHECKING AND CORRECTIVE ACTION

4.1 Inspection, Measurement and Monitoring

Expectations:

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

References:

OPR-99 Sections 36, 39, 47, 53(1) and 54(1)
CSA Z662-11 Clauses 10.2.2 and 10.14.1
CLC Part II Sections 125(1)(c), 134.1(4)(d), 135(7)(k), 136(5)(g), 136(5)(j)
COHSR Sections 4.5, 4.6, 5.10, 6.10(3), 10.18, 12.3, 12.14, 14.20, 14.21, 14.23, 15.6, 17.3, 17.9

Assessment:

SET-PTC holds various recurrent meetings and completes reports which monitor and document the EHS MS safety component, including:

• daily and monthly progress reports;
• daily and weekly safety inspection reports;
• daily tool box meetings;
• weekly all staff meetings;
• weekly fire drills;
• weekly behaviour-based inspections;
• OSC Safety Tours;
• incident reporting; and
• incident investigation (which, when required, are tracked in the Incident Investigation Reporting (IIR) system).

SET-PTC indicated that the Environment Performance and Safety System (EPASS) tracking system are expected to be in place January 2013.

Document review confirmed that actions resulting from the above-listed activities are assigned and tracked to ensure all issues are addressed and reported. SET-PTC tracks the actions until completion and verifies their effectiveness.

The Accountability Management and Performance Management assessments determine employee competency and identify future training initiatives.

The audit found that SET-PTC has adequate processes in place to ensure safety-related incidents are investigated and that the appropriate measures are taken to correct or prevent further deficiencies in its execution of the EHS MS. Therefore the Board finds SET-PTC to be Compliant with this sub-element.

Compliance Status: Compliant

4.2 Corrective and Preventive Actions

Expectations:

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

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

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

References:

OPR-99 Sections 6 and 52
CSA Z662-11 Clauses 3.1.2(g),(h) and10.5
CLC Part II Sections 125(1)(c), 125(1)(o), 125.1(f), 134.1(4)(d), 135(7)(e), 135(7)(j), 136(5)(g)
COHSR Sections 2.27, 7.3, 10.4, 10.5, 15.4, 19.1(1)

Assessment:

SET-PTC’s Regulatory Incident Reporting Guidelines for On-Call Supervisors (Guidelines) is approved and communicated to control teams and on-call incident supervisors. The purpose of the Guidelines is to assist SET-PTC’s On-Call Supervisors and On-Call Incident Supervisors in the external reporting of “regulatory reportable” incidents that occur in both its federally and provincially regulated facilities. This regulatory reporting practice was put in place to ensure timely notification of reportable occurrences to the appropriate regulatory agency regardless of where the incident occurs across the facilities. The Guidelines are controlled by the incident management program and are reviewed on an annual basis by all stakeholders to ensure their currency. The One-Window Reporting Procedures, embedded in the EHS Checklist, are reviewed on initial hiring, and annually thereafter. Evidence of this checklist review was found in the LMS.

SET-PTC has developed and implemented a comprehensive incident investigation process. The incident reporting and investigation process includes near misses, and includes contractors in incident investigations when appropriate. The investigation process identifies root causes. Incidents are analyzed to detect patterns or trends to anticipate and prevent future incidents. The incidents and accidents are recorded and reported as per policy. Best practices and lessons learned are shared with internal stakeholders and contractors who can benefit.

The audit found that the NEB Assurances of Voluntary Compliance (AVCs) are currently being tracked on the Scorecard; however, no targets for continual improvement have been established. Board Inspection Officer Orders and Board Orders are not tracked on the Scorecard and therefore it is unclear whether senior management is being made aware of such enforcement measures. As an example, a Board Inspection Officer Order was issued to Westcoast in September 2012; however there is no record of this enforcement measure being discussed at any of the senior management level meetings (Weekly OSC or Bi-Monthly Audit Review Meetings).

As there is inconsistency in the communication, tracking and resolution of non-compliances outlined in Board Inspection Orders, the Board finds SET-PTC to be non-compliant with respect to this sub element.

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 47 and 56
CSA Z662-11 Clauses 9.11, 3.1, 10.5, and10.4
CLC Part II Sections 125(1)(g)
COHSR Sections 1.5, 2.23, 2.24, 2.27(7), 4.6 5.17, 5.18, 6.10(7), 7.3(6), 8.18(3), 10.6, 10.15, 10.19(4), 11.12, 12.14, 14.23(4), 15.11, 16.13(2), 17.4(4), 17.8(2), 17.9(2), 17.10(2), 18.39, 18.40, 18.41, 18.42, 19.6(5), 19.8(2)

Assessment:

The Board confirmed through documentation and record review that SET-PTC has implemented a record retention process which includes appropriate types of records to be retained, retention and disposition timeframes and disposal methods. Copies of all records requested were made readily available.

SET-PTC has several repositories for safety-related information. The IIR system is used for tracking incidents. Hard copies of these incident records are maintained in the regional offices. The SET-PTC Document Management and Retention Standard are posted on the EHS website. An electronic communication, announcing this mechanism, was sent to all employees from Spectra Energy Records Management.

While all records requested were readily retrieved, it was indicated during interviews that the company lacked a formalized process for email correspondence retention. The company has established that all unfiled emails will be deleted after three months and those that have been moved to a folder are deleted after two years. Individual staff have established their personal method in ensuring that these records are maintained; however, the Board is concerned that, without a formal filing process, certain email correspondence which contain compliance information may be deleted and not easily accessible in the event of an investigation.

Based on documents reviewed and interviews conducted it was determined that SET-PTC has an inadequate records management strategy in place and is therefore found to be non- compliant with this sub-element.

Compliance Status: Non-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 Z662-11 Clauses 3.1.2 (c) and (h)(iii)
COHSR Section 19.7(1)(2)

Assessment:

The operation of SET-PTC’s facilities and pipelines are subject to periodic audits by Spectra Energy Corporation’s internal audit services and EHS audit groups.

SET-PTC’s audit team in Calgary conducts audits on capital expansion projects, while safety audits are conducted by its Manager Internal Audits, based out of Houston, Texas. The audit cycle is determined by a comprehensive risk assessment. Local subject matter experts are contracted to ensure appropriate legislation is included in the protocol for the facilities being audited.

The Senior Management of Spectra Energy Corporation and its Board of Directors approve audit risk assessment methodologies and annual audit plans of Spectra Energy Corporation’s internal audit services and EHS audit groups. Performance based audits are being conducted. TeamMateTM audit management software is being used to ensure action items are closed-out. TeamCentral,TM an audit management database, is used for tracking audit projects, issues and recommendations.

It was verified through interviews and document review that SET-PTC has an internal audit program to assess its EHS MS against its regulatory requirements. However, the audit found that the absence of an effective process to identify and integrate all of the legal operational safety requirements, previously referenced in Legal Requirements sub-element 2.2, could lead to incomplete EHS audit protocols and inaccurate internal audit findings. Furthermore, the specific discipline audits conducted are performance audits, not compliance or technical audits, and the Board was unable to confirm that SET-PTC has conducted an internal audit that included all management systems in its scope (i.e., Integrity, Safety, Environment, Emergency Management, Public Awareness and Crossings).

Based on documents reviewed and interviews with operations staff, SET-PTC was not able to demonstrate that it was in compliance with the requirements of this sub-element.

Compliance Status: Non-Compliant

5.0 MANAGEMENT REVIEW

Expectations:

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

References:

OPR-99 Section 55
CSA Z662-11 Clause 3.1.2(h) (iii)
COHSR Sections 11.2(4), 12.10(1.2), 19.6(3), 19.7(1)-(2)

Assessment:

SET-PTC’s EHS MS Performance Standard 9.4 (Management System Review) establishes minimum expectations for conducting a Management System Review with senior management to determine whether changes to the EHS Policy, EHS goals and targets, or other elements of the EHS MS are necessary to ensure effectiveness of the EHS MS based on EHS audit results, EHS performance, changing business needs and/or stakeholder inputs. The Management System Review is conducted at least annually, preferably in the third quarter.

Management System Reviews may be conducted more frequently when:

• − important new EHS regulatory or EHS issues arise;
• − significant hazards/risks are identified; or
• − previous audits/assessments have identified on-going deficiencies in the EHS MS.

Although the audit found there was a level of oversight provided, given the absence of rigor in the reporting and tracking of non-compliances, as well as the deficient audit process described in sub-element 4.4 of this appendix, the Board has determined that senior management review in this instance has not been undertaken with a view to ensuring the EHS MS’s continuing suitability, adequacy and effectiveness. Accordingly, SET-PTC has been found to be non-compliant with this sub-element.

Compliance Status: Non-Compliant

Date modified:

2020-09-29