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444 Seventh Avenue SW
Calgary, Alberta
T2P 0X8
National Energy Board Onshore Pipeline Regulations (OPR)
Final Audit Report of the TransCanada
Emergency Management Program
File Number: OF-Surv-OpAud-T211-2013-2014 01
TransCanada PipeLines Limited and National Energy Board-Regulated Subsidiaries (TransCanada)
450-1st Street SW
Calgary, Alberta T2P 5H1
31 March 2014
Executive Summary
NEB-regulated companies must demonstrate a proactive commitment to continual improvement in safety, security, and environmental protection. Pipeline companies under the Board’s regulation are required to incorporate effective and implemented Management Systems into their day-to-day operations. These systems include the tools, technologies and actions needed to ensure that pipelines are safe, and remain that way over time. Emergency management programs enable pipeline companies to respond efficiently and effectively in the event of an emergency situation.
This report documents the Board’s comprehensive audit of TransCanada’s Emergency Management Program as it applies to its NEB-regulated subsidiaries and pipeline facilities. The audit was conducted using the National Energy Board Onshore Pipeline Regulations (OPR) as amended on 21 April 2013. The OPR, among other things, requires companies to have an effective and well-documented emergency management program as a key component of their Management Systems. The OPR was promulgated with no implementation grace period for the Board’s regulated companies.
The Board’s audit was conducted following its Audit Protocol, which identifies five Management System elements. These five elements are further broken down into 17 sub-elements. Each sub-element reflects a number of regulatory requirements. The NEB requires companies to be compliant with one hundred percent of the regulatory requirements of a sub-element being assessed. If a company’s program is found to be deficient with respect to any regulatory requirement, the entire sub-element will be found in Non-Compliance.
The Board’s audit finds TransCanada has developed an emergency management program that addresses the identified hazards and risks associated with potential incidents or emergencies on its pipelines. The documents and records reviewed during this audit demonstrate that TransCanada is ensuring company personnel, along with people living and working near pipelines, are appropriately informed of and/or trained in, emergency management practices and procedures in the event of an emergency. TransCanada has also demonstrated both that it has emergency response procedures in place for its facilities, and that these procedures are tested through an annual schedule of emergency response exercises, conducted across all of its operational regions.
The audit also identified a number of Non-Compliant findings, the majority of which fall into three general categories:
- the lack of documented processes that correspond with the Management System requirements as required by the recently updated OPR;
- the development and implementation of effective processes related to ongoing, internal evaluation of the compliance to legal requirements, and the adequacy and effectiveness of its Emergency Management Program; and
- full implementation of existing processes particularly regarding the integration of external resources that play a role in TransCanada’s emergency response.
The Board has determined that no enforcement actions are immediately required to address the Non-Compliant findings identified in this audit. Within 30 days of the Final Audit Report being issued, TransCanada must develop and submit a Corrective Action Plan for Board approval detailing how it intends to resolve Non-Compliances identified by this audit. The Board will assess the implementation of the corrective actions to confirm that they are completed in an expedient manner, and on a system-wide basis. The Board will also continue to monitor the overall implementation and effectiveness of TransCanada’s Management Systems through targeted compliance verification activities as a part of its on-going regulatory mandate.
Table of Contents
- 1.0 Audit Terminology and Definitions
- 2.0 Abbreviations
- 3.0 Introduction: NEB Purpose and Framework
- 4.0 Background
- 5.0 Audit Objectives and Scope
- 6.0 Audit Process and Methodology
- 7.0 Audit Activities
- 8.0 Program Summary
- 9.0 Summary of Findings
- 10.0 Conclusions
Appendices
- Appendix I: Audit Evaluation Table
- Appendix II: Facility Summaries and Maps
- Appendix III: Company Representatives Interviewed
- Appendix IV: Documents Reviewed
1.0 Audit Terminology and Definitions
Audit: A systematic, independent and documented process for obtaining evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled.
Compliant: A program element meets legal requirements. The company has demonstrated that it has developed and implemented programs, processes and procedures that meet legal requirements.
Corrective Action Plan: Addresses the Non-Compliances identified in the Audit Report and explains the methods and actions which will be used to "correct" them.
Finding: The evaluation or determination of the adequacy of programs or elements in meeting the requirements of the National Energy Board Act, Part II of the Canada Labour Code, and their associated regulations.
Non-Compliant: A program element does not meet legal requirements. The company has not demonstrated that it has developed and implemented programs, processes and procedures that meet the legal requirements. A corrective action must be developed and implemented.
Procedure: A documented series of steps followed in a regular and defined order allowing individual activities to be completed in an effective and safe manner. The procedure will also outline roles, responsibilities and authorities required for completing each step.
Process: A systematic series of actions or changes taking place in a definite order and directed towards a result.
Program: A documented set of processes and procedures to regularly accomplish a result. The program outlines how plans and procedures are linked, and how each one contributes towards the result.
2.0 Abbreviations
CAP: Corrective Action Plan
CLC: Canada Labour Code Part II
COHSR: Canada Occupational Health and Safety Regulations
EM: Emergency Management
EP: Environmental Protection
GOT: Goals, Objectives and Targets
HS&E: Health Safety & Environment
IIT: Incident and Issue Tracking
NEB: National Energy Board
NGTL: Nova Gas Transmission Ltd.
OPR: National Energy Board Onshore Pipeline Regulations
SM: Safety Management
TOPs: TransCanada Operating Procedures
TransCanada: TransCanada PipeLines Limited and its NEB-regulated subsidiaries
TQM: TransCanada Québec & Maritimes Pipeline Inc.
3.0 Introduction: NEB Purpose and Framework
The NEB’s purpose is to promote safety and security, environmental protection, and efficient energy infrastructure and markets in the Canadian public interest within the mandate set by Parliament in the regulation of pipelines, energy development and trade.
To evaluate a regulated company’s compliance with its regulations, the NEB undertakes Management System audits of its regulated companies. The NEB requires that each company demonstrate the adequacy and implementation of the methods the company has selected and employed in order to proactively identify and manage hazards and risks to achieve Compliance.
Following the audits, companies are required to submit and implement a Corrective Action Plan to address all findings of Non-Compliance. The results of the audits are considered as a part of the NEB’s risk-informed life cycle approach to compliance assurance.
4.0 Background
TransCanada operates approximately 42,000 km of federally regulated pipeline from British Columbia to Quebec. In order for the audit of TransCanada to reflect the way it runs its operations, the NEB audited each program separately. Therefore, this audit is one of a series of six program audits having been undertaken by the Board with respect to NEB-regulated facilities operated within TransCanada’s organization. The audits are titled:
- TransCanada Integrity Management Program Audit; (Final Audit Report released February 2014)
- TransCanada Safety Management Program Audit;
- TransCanada Environmental Protection Program Audit;
- TransCanada Emergency Management Program Audit;
- TransCanada Third Party Crossings Program Audit; and
- TransCanada Public Awareness Program Audit.
These audits identified that TransCanada operates its facilities using a common organizational and technical management structure for all of the facilities noted. Some of the findings are therefore similar in each audit, and the individual audit reports reflect this. During the audit, the Board reviewed and evaluated a sample set of facilities based on the individual activities, as well as the associated hazards and risks, as reflected in the individual audit reports. To evaluate its Emergency Management Program, the Board also attended some of TransCanada’s planned emergency response exercises.
5.0 Audit Objectives and Scope
The objective of the audit was to determine the adequacy and effectiveness of TransCanada’s Emergency Management Program. The requirements against which TransCanada was audited are contained within:
- The National Energy Board Act;
- The National Energy Board Onshore Pipeline Regulations;
- Canada Labour Code Part II (CLC);
- Safety and Health Committees and Representatives Regulations made under Part II of the CLC;
- Canadian Occupational Health and Safety Regulations made under Part II of the CLC; and,
- TransCanada’s policies, programs, practices and procedures.
In utilising the OPR, the Board notes its amendment on 21 April 2013, which clarified the Board’s expectations for establishing and implementing a formal Management System and Emergency Management Program. These amendments were preceded by consultation between the Board and its regulated companies, and accordingly the OPR was not promulgated with an implementation grace period. As a result, the audit of TransCanada’s Emergency Management Program was conducted using the amended OPR.
The scope of the audit included the following companies that hold certificates to operate in Canada:
- TransCanada PipeLines Limited;
- TransCanada Keystone Pipeline GP Ltd.;
- Trans Québec & Maritimes Pipeline Inc. (TQM);
- Foothills Pipe Lines Ltd.; and
- NOVA Gas Transmission Ltd. (NGTL).
These subsidiaries hold the certificates for TransCanada’s NEB-regulated facilities, which include the Canadian Mainline (operating under TransCanada PipeLines Limited), Keystone Pipeline (operating under TransCanada Keystone Pipeline GP Ltd.), TQM Pipeline System (operating under Trans Québec & Maritimes Pipeline Inc.), Foothills System (operating under Foothills Pipe Lines Ltd.), and the Alberta System (operating under NGTL). For more TransCanada facility information, refer to Appendix II of this report.
6.0 Audit Process and Methodology
TransCanada and its NEB-regulated subsidiaries operate approximately 42,000 kilometres of federally regulated pipeline across the country. TransCanada and its subsidiaries operate these facilities using a common organizational and technical Management System. Accordingly, and in order to complete an assessment of its Management System in a reasonable timeframe, the Board elected to audit and assess a representative sample of TransCanada and its subsidiaries utilizing a risk-informed approach that included a review of previous compliance history.
The Board chose to use NGTL and the Alberta System as its representative sample. The Board also included areas of the TransCanada system presenting unique potential hazards to assess system-specific hazards. Due to the unique hazards introduced to an emergency management program by the transportation of liquids including oil, the specific processes, plans and procedures applicable to the Keystone pipeline were also reviewed.
TransCanada has divided its Canadian facilities and assets into five operational regions. These regions are the Wildrose Region, Rocky Mountain Region, Central Region, Northern Ontario Region and Eastern Region. As TransCanada applies the same Emergency Management Program across all of its systems, any findings and corrective actions required will be applied across all of TransCanada’s systems and subsidiaries. The NEB will verify the implementation of any corrective actions with subsequent compliance verification activities at each subsidiary once TransCanada’s Corrective Action Plan has been approved by the Board, and implemented.
TransCanada’s utilization of one set of policies and procedures for its Emergency Management Program also guided the implementation of the Board’s audit process. Interviews and document review on the Emergency Management Program were conducted at the Head Office in Calgary, Alberta. Site visits were conducted at select NGTL facilities, and two field emergency response exercises were observed. During these site visits, activities were evaluated for each Management System element through interviews with a number of personnel at various levels, as well as document and record review.
7.0 Audit Activities
The audit involved Board review of TransCanada company documents, interviewing company representatives at all levels of the organization, and conducting field verification of compliance with NEB requirements at selected sites. Information gathered was then synthesized using the Board’s established Audit Protocol.
On 19 June 2013, an opening meeting was conducted with representatives from TransCanada in Calgary, Alberta to discuss the Board’s audit objectives, scope and process. A schedule for conducting the staff interviews and site verifications was also developed at this meeting. Throughout the audit, daily summaries with action items were provided to TransCanada.
On 24 October 2013, the Board held an audit Pre-Close-Out meeting with TransCanada to discuss additional information that could be of value to the Board prior to compiling its draft audit report. An audit Close-Out meeting was held on 6 November 2013.
For a list of TransCanada representatives interviewed, refer to Appendix III. For a list of documents and records reviewed, refer to Appendix IV.
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8.0 Program Summary
TransCanada’s Emergency Management Program applies to all TransCanada corporate entities and the operation of all TransCanada natural gas and oil pipelines and associated facilities in Canada, as well as the United States and Mexico. It is implemented out of TransCanada’s head office in Calgary by its Emergency Management Team.
The Emergency Management Team is responsible for:
- program development;
- review and maintenance;
- establishing emergency management criteria;
- development of emergency management training;
- managing the response structure;
- communications and reporting;
- ensuring compliance with regulatory requirements; and
- conformance with TransCanada processes and procedures.
The Emergency Management Team provides emergency management services to all TransCanada entities and reports to the Health Safety & Environment Committee of TransCanada’s Board of Directors.
The TransCanada Emergency Management Program includes elements for emergency management system standards, process implementation and maintenance, management review, communications, emergency preparedness, goals and objectives, inspections, third party audits, and other Management System elements. It also establishes the programs and procedures for hazard identification and assessment, emergency preparedness, emergency response exercises, training, mutual aid, reporting, compliance, as well as education, liaison and awareness for response agencies and the public.
In addition to receiving oversight by the Emergency Management Program, TransCanada’s Keystone pipeline is subject to the TransCanada Emergency Response Program. As an oil transporting facility, it has its own emergency response procedures setting out the hazards, mapping, roles, response procedures, controls, response partners and other emergency management elements required for an effective emergency response in the event of an oil-related emergency.
TransCanada has also developed and implemented continuing education, liaison and awareness programs for the public, and first responders potentially involved in, or affected by, an emergency associated with its facilities. These programs are supported by TransCanada’s corporate Public Awareness Program.
9.0 Summary of Findings
The Board’s audit was conducted following its Audit Protocol, which identifies five Management System elements. These five elements are further broken down into 17 sub-elements. Each sub-element reflects a number of regulatory requirements. The NEB requires companies to be compliant with one hundred percent of the regulatory requirements of a sub-element being assessed. If a company is found to be deficient with respect to any regulatory requirement, the entire sub-element will be found Non-Compliant. A Corrective Action Plan will be required in order to demonstrate to the Board that appropriate actions will be taken to achieve full Compliance.
The following summary represents a high-level overview of the Board’s audit findings for TransCanada’s Emergency Management Program based on information provided for the audit. Details of how each of the audited elements impacts the Emergency Management Program and a full description of the Board’s assessment for each of its Management System sub-elements can be found in Appendix I of this report.
Element 1.0 - Policy and Commitment
Sub-element 1.1 - Leadership and Accountability
The position of accountable officer was introduced into the OPR in April of 2013. The Board is satisfied that TransCanada has appointed an accountable officer and outlined the responsibilities of this position in accordance with the regulations and submission deadlines. Subsequent NEB compliance activities will verify the adequacy and effectiveness of the process implementation once a full planning cycle has been completed. As a result, the Board finds TransCanada’s to be Compliant with this sub-element.
Sub-element 1.2 - Policy and Commitment Statements
TransCanada demonstrated that it has established and implemented a Health Safety & Environment Commitment Statement and Code of Business Ethics that include protection of the public, workers and the environment and immunity from disciplinary action for employees that report any actual or suspected violation of the law. Following review, the Board has determined that these documents do not demonstrate the existence of policies 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. As a result, the Board finds TransCanada to be Non-Compliant with this sub-element.
Element 2.0 - Planning
Sub-element 2.1 - Hazard Identification, Risk Assessment and Control
TransCanada demonstrated that overall, its Emergency Management Program incorporates processes to assess risk, identify hazards, and introduce controls to mitigate them. The Board also considers TransCanada’s hazard identification and risk assessment process for the Keystone pipeline to be adequate as it identifies and verifies both highly sensitive receptors, and control points for the execution of emergency response activities to mitigate the consequences of an emergency event. Given, however, that this process, and the similar processes for its gas carrying facilities were not demonstrated to be fully implemented, the Board finds TransCanada to be Non-Compliant with this sub-element.
Sub-element 2.2 - Legal Requirements
TransCanada demonstrated it is tracking, listing and conducting some internal notifications regarding its legal responsibilities as it related to regulatory changes. However, it did not demonstrate it has, or maintains, a complete list of legal requirements. It also did not demonstrate an effective process to ensure regulatory changes trigger necessary program changes or communication to all staff involved in the Emergency Management Program. As a result, the Board finds TransCanada to be Non-Compliant with this sub-element.
Sub-element 2.3 - Goals, Objectives and Targets
TransCanada demonstrated that it is establishing and tracking aspects of its emergency management performance specifically related to training and the testing of equipment. However, TransCanada did not demonstrate a documented process for development, implementation, maintenance and review of the adequacy and effectiveness of goals, objectives and targets for its Emergency Management Program. Also, while performance measures and targets exist for some components such as exercises and training, the Board found that TransCanada has not established goals, objectives and targets for other Emergency Management Program components such as consultation/continuing education and liaison with response agencies, response times and communications with stakeholders and the public. Based on all the foregoing, the Board finds TransCanada to be Non-Compliant with this sub-element.
Sub-element 2.4 - Organizational Structure, Roles and Responsibilities
TransCanada demonstrated it has a documented organizational structure for its Emergency Management Program. However, this structure did not in the Board’s view, demonstrate that TransCanada’s annual organizational evaluation effectively assesses the external human resources needed to respond to an incident. The Board believes external resources play an important role in the event of an emergency and finds that TransCanada’s monitoring of external human resources is not sufficient to meet the Board’s expectations. As such, the Board finds TransCanada to be Non-Compliant with this sub-element.
Element 3.0 - Implementation
Sub-element 3.1 - Operational Control-Normal Operations
The Board expects companies to have ongoing preparatory processes in place that function during normal operating conditions to develop and maintain effective emergency management programs, and implement continual improvement initiatives. Based on the information provided, the Board found TransCanada’s processes for developing and implementing corrective, mitigative, preventive and protective controls associated with the hazards and risks of its operations to meet its expectations. As a result, the Board finds TransCanada to be Compliant with this sub-element.
Sub-element 3.2 - Operational Control-Upset or Abnormal Operating Conditions
The Board notes that TransCanada has developed processes and plans to identify the potential for upset or abnormal conditions as well as methods to test the adequacy of its contingency plans. However, at the time of the audit, these processes and plans were not, in the Board’s view, fully implemented or effective to meet the Board’s expectations. As a result, the Board finds TransCanada to be Non-Compliant with this sub-element.
Sub-element 3.3 - Management of Change
In the context of the Emergency Management Program, the Board noted integrated procedures that establish the process to identify a proposed change, the stakeholders involved, the steps to implement the change, and a target implementation date. However, the documents created by these procedures did not demonstrate that changes having an effect on emergency response planning were reflected in the Emergency Management Program through an update to procedures or response plans.
In the context of broader management of change processes that could affect the Emergency Management Program, TransCanada did not demonstrate that it has an established and implemented a process for identifying and managing change that could affect safety, security or protection of the environment, including new hazards or risks, changes in design, specifications, standards or procedures, and change in the company’s organizational structure or the legal requirements. As a result, the Board finds TransCanada to be Non-Compliant with this sub-element.
Sub-element 3.4 - Training, Competence and Evaluation
TransCanada demonstrated effective processes for developing and implementing competency requirements and training programs. For internal training, TransCanada has developed documented emergency management role training profiles and competency requirements for each role in the Emergency Management Program. There are requirements for regional and corporate employees with a potential emergency role to complete emergency training modules as set out in the emergency management role training profiles. Having all the required training is a key performance indicator in each employees’ documented annual performance agreement. TransCanada also provides experiential training to external parties through their participation in TransCanada’s field and table top exercise program. As a result, the Board finds TransCanada to be Compliant with this sub-element.
Sub-element 3.5 - Communication
TransCanada demonstrated a process relating to external and internal communication requirements that meets the Board’s expectations. For external communication, TransCanada’s Emergency Management Program has implemented a plan directed at its external stakeholders, including first responders and adjacent landowners and has integrated some of the outreach components of its Emergency Management Program with its Public Awareness Program for the purposes of communication, consultation, and liaison with, first response agencies and other services that may have a response role in the event of a TransCanada pipeline incident. TransCanada also uses several methods to communicate emergency management information across its organization. As a result, the Board finds TransCanada to be Compliant with this sub-element.
Sub-element 3.6 - Documentation and Document Control
The Board found TransCanada’s process relating to establishing and implementing effective processes for identifying and managing documents required to meet its expectations. This process creates a framework for the development and maintenance of the documentation necessary for TransCanada employees and contractors to efficiently and correctly conduct the operational and maintenance activities associated with TransCanada’s facilities. As a result, the Board finds TransCanada to be Compliant with this sub-element.
Element 4.0 - Checking and Corrective Action
Sub-element 4.1 - Inspection, Measurement and Monitoring
TransCanada demonstrated that it has implemented effective processes for inspecting and monitoring its activities and facilities and for evaluating the adequacy and effectiveness of its Emergency Management Program. TransCanada also demonstrated that it has several processes for inspecting and monitoring its equipment, activities and emergency response plans related to its Emergency Management Program, and several methods to monitor and measure its performance. As a result, the Board finds TransCanada to be Compliant with this sub-element.
Sub-element 4.2 - Investigating and Reporting Incidents and Near-misses
This sub-element was examined through review of TransCanada’s Incident and Issue Tracking process, its intended function, and how its function is demonstrated within the overall HS&E Management System. In addition, the Board assessed how the process is communicated to employees. TransCanada was able to demonstrate that it has a process in place to identify, track, analyze and resolve emergency management issues and incidents throughout its Incident and Issue Management Program that reflects the Board’s expectations. As a result, the Board finds TransCanada to be Compliant with this sub-element.
Sub-element 4.3 - Internal Audit
TransCanada was able to demonstrate that its quality assurance program is implemented on a scale that exceeds the Board’s expectations with respect to frequency. However, its implementation to measure performance relative to internal TransCanada requirements that are derived from statutory requirements does not meet the Board’s expectations.
The Board is of the view that companies must have a process whereby the status of the program’s compliance with the express statutory requirements can be verified. As a result, and given TransCanada did not demonstrate it has or maintains a complete list of legal requirements, the Board finds TransCanada to be Non-Compliant with this sub-element.
Sub-element 4.4 - Records Management
The Board found TransCanada’s process relating to 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, to meet its expectations. As a result, the Board finds TransCanada to be Compliant with this sub-element.
Element 5.0 - Management Review
Sub-element 5.1 - Management Review
TransCanada demonstrated that it is undertaking a significant number of management review activities consistent with the descriptions included in TransCanada’s Health Safety & Environment Framework document. However, the Board considers senior management’s involvement and performance in particular areas to be critical. These include evaluating and managing the results of audits, and the results of compliance verification activities conducted by regulatory agencies. The Board has made findings of non-compliance in other sub-elements dealing with the development of the scope of company audits, and the development and implementation of corrective action plans, which it views to properly fall within the care and control of senior management. In addition, TransCanada was unable to demonstrate a documented and comprehensive management review process of the Emergency Management Program describing activities for adequately and effectively undertaking management reviews on a consistent basis and for ensuring continual improvement. As a result, the Board finds TransCanada to be Non-Compliant with this sub-element.
10.0 Conclusions
NEB-regulated companies must demonstrate a proactive commitment to continual improvement in safety, security, and environmental protection. Pipeline companies under the Board’s regulation are required to incorporate effective and well-implemented Management Systems into their day-to-day operations. These programs include the tools, technologies and actions needed to ensure that pipelines are safe and remain that way over time.
Over the course of this audit TransCanada was required to demonstrate the adequacy and effectiveness of its Management System and Emergency Management Program. The Board reviewed documentation and records provided by TransCanada, conducted interviews with TransCanada staff and attended TransCanada’s emergency response exercises. Based on this review, the Board finds TransCanada has developed and implemented an Emergency Management Program that addresses significant identified hazards and risks associated with potential incidents or emergencies on its pipelines.
Notwithstanding the scope of work being undertaken by TransCanada and its processes in place, the audit identified a number of non-compliant findings, the majority of which fall into three general categories:
- the lack of documented processes that correspond with the Management System requirements as required by the recently updated OPR;
- the development and implementation of effective processes related to ongoing, internal evaluation of the compliance to legal requirements, and the adequacy and effectiveness of its Emergency Management Program; and
- full implementation of existing processes particularly regarding the integration of external resources that play a role in TransCanada’s emergency response.
The Board has determined that while no immediate enforcement actions are required to address these Non-Compliant findings, as per the Board’s standard audit practice, TransCanada must develop and submit a Corrective Action Plan describing its proposed methods to resolve the non-compliances identified, and the timeline in which corrective actions will be completed. TransCanada will be required to submit its Corrective Action Plan for approval within 30 days of the Final Audit Report being issued by the Board. The Board will make its Final Audit Report and TransCanada’s approved corrective action plan public on the Board’s website.
The Board will assess the implementation of all of TransCanada’s corrective actions to confirm they are completed in a timely manner and on a system wide basis until they are fully implemented. The Board will also continue to monitor the overall implementation and effectiveness of TransCanada’s Emergency Management Program and management system as a whole through targeted compliance verification activities as a part of its ongoing regulatory mandate.
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