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 IV - Emergency Management Program Audit Evaluation Table

Appendix IV
Westcoast Energy Inc., carrying on business as
Spectra Energy Transmission (Westcoast)
Emergency Management 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
  • 5.1 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 and 48
CSA Z662-11 Clause 3.1.2(a)

Assessment:

Westcoast provided an adequate and up-to-date corporate Environment, Health and Safety Policy which meets the Board’s expectations. The Policy statement and accompanying documentation outline Westcoast’s management principles and clear program objectives. The Emergency Management Program (EMP) is guided by these documents. The review of Westcoast’s overarching Emergency Management (EM) Manual indicated that the company has developed EM-specific policy documents which build on the corporate policy documents. All staff interviewed were aware of the existence and content of the appropriate policy documents.

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, 33, 37, 39, 40, 47 and 48
CSA Z662-11 Clause 3.1.2 (f),

Assessment:

During review of Westcoast’s EM manuals and interviews with staff, Westcoast was able to demonstrate that it had identified and risk-assessed the hazards associated with its facilities. Westcoast demonstrated that it had developed and implemented processes for the identification of its EM planning zones (EPZ) associated with the hazards posed by its pipelines and associated facilities. Westcoast staff also provided information and records describing the processes it uses to re-validate its EPZ on a periodic basis. Westcoast staff demonstrated that the hazard identification processes and EPZ were being utilized in the development of its other EM-related activities including its awareness, continuing education and liaison programs.

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, 32, 40, 47 and 48

Assessment:

Through record and document review, EM staff demonstrated that Westcoast has developed and implemented adequate processes and activities for the identification and integration of the legal requirements related to its EM obligations.

Further, Westcoast staff demonstrated that the company is actively involved in the development and improvement of the various technical standards utilized by industry. This demonstrates Westcoast’s commitment not only to meeting its requirements but also to improving safety and response practices.

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 Z662-11 Clause 3.1.2(h)(ii)

Assessment:

Westcoast EM staff was able to demonstrate compliance with this sub-element through documentation and records provided to the Board. Westcoast’s corporate emergency management manual contains clear objectives for the EM program. Westcoast sets annual targets related to its exercise program on an annual basis. As well, review of Westcoast’s EM exercise documentation and records indicates that specific objectives are set, measured and managed for each exercise conducted.

Similarly, Westcoast EM staff provided documents and records to demonstrate that it routinely sets and measures objectives associated with its interactions with other response agencies.

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 and 48
CSA Z662-11 Clauses 3.1.2(b) and 10.5.2.4

Assessment:

Westcoast EM staff was able to demonstrate compliance with this sub-element through documentation and records provided to the Board. While Westcoast was not able to demonstrate that it has a formal and repeatable process for evaluating the adequacy of its staff in preparing for and responding to an emergency, the company was able to demonstrate that it had an adequate organizational structure and resourcing levels for its present facilities. Westcoast has:

• developed a full complement of facility emergency response plans (FERPs);
• four dedicated emergency response professionals on staff;
• participated actively in industry committees and standard development; and
• undertaken a significant volume of work related to emergency response exercises and drills, as well as continuing education and liaison programs.

Further, Westcoast staff demonstrated that senior management routinely seeks information regarding EM resourcing.

With respect to resourcing levels, Westcoast is advised that the updated OPRs presently in the parliamentary review process require companies to develop, implement and demonstrate formal resourcing management practices, which Westcoast does not currently have. Further, while present resourcing levels appear adequate, Westcoast’s proposed pipeline facilities related to LNG expansion in BC will require on-going monitoring and management of its operational resourcing.

Through document and record review, as well as interviews with staff, Westcoast was able to demonstrate compliance with respect to the Board’s expectations regarding roles and responsibilities.

Westcoast provided roles and responsibility statements and documents for all staff involved in the management, development and implementation of the EMP. All company staff interviewed was able to clearly demonstrate knowledge of their involvement and expectations with the management of the program.

Companies must be able to demonstrate that they have a clearly defined organizational structure including documented roles and responsibilities for all staff who could be involved in an emergency. Westcoast was able to demonstrate that it meets the requirements with respect to having an appropriate EM structure including appropriately defined roles and responsibilities for staff involved in a response. Westcoast provided EM response organization charts, role and responsibility statements, and job descriptions. Westcoast demonstrated that it trains its staff in the formal Incident Command System (ICS) at the BC Justice Institute. ICS is an internationally recognized organizational system for providing oversight and management of emergencies. Westcoast staff receives ICS 100 through 300 training dependant on expected roles. As well, Westcoast has developed formal documentation outlining their management related roles and provided training on same.

Further, Westcoast provided formal documentation for the organization and use of mutual aid practices between the various companies located in the Taylor, BC, area where transmission facilities cross congested industrial areas.

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 Z662-11 Clause 3.1.2(g)

Assessment:

Westcoast demonstrated that it has a formal process and dedicated staff for managing changes to its assets. However, Westcoast’s management of change (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;
• changes to industry standards or practices
• the identification of new hazards; or
• results of monitoring, inspections or investigations.

Further, Westcoast’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.).

With respect to the EM program MOC, on a less formalized basis, the EM coordinator and staff do proactively identify and manage changes to the EM program and documentation in an adequate manner. Westcoast EM staff demonstrated that internal activities such as Leave-to-Open requests, decommissioning applications, incident investigations, etc., are routinely monitored to evaluate their impact on the EM program and that changes are made as required. However, as this practice is not fully proceduralized, and given the non-compliant finding associated with the formal company-wide MOC process, this sub-element is found to be non-compliant.

EM staff provided a draft Emergency Preparedness Management System that included requirements for management of change. This was being undertaken in anticipation of the Board’s updated OPR requirements and the draft findings of the NEB Processing Plant Audit Report. While not reviewed because of its draft nature, this anticipatory work was viewed as a positive practice.

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 Z662-11 Clauses 3.1.2(ii) and 10.5.2.4

Assessment:

Through document and record review, as well as interviews with staff, Westcoast was able to demonstrate compliance with this sub-element.

Westcoast provided documented EM training requirements that were appropriate for the facilities audited. Record review indicated that the EM training program was being monitored on a regular basis by the EM coordinator, the Operations Steering Committee, and other senior management. Staff receives EM information, guidance and training starting with the employee induction process and continuing throughout their employment with Westcoast. As noted in sub-element 3.1, Organizational Structure, Roles and Responsibilities above, staff and management receive training in formal incident command practices and procedures which allows for an integrated response (with other first responders) utilizing a common, standardized structure. Westcoast provided copies of its EM training handbooks and knowledge checklists used by instructors to ensure consistent learning practices.

EM training and competency requirements include, in addition to knowledge-based training for company personnel, the need to demonstrate an ability to respond to the various emergencies that may occur at the facilities. As well, the company demonstrated that it has developed a program of continuing education and awareness for other first responders who may attend or manage emergencies involving the regulated facilities. Westcoast provided documents and records detailing robust and all-inclusive continuing education, awareness and exercise programs involving company staff, local (e.g., municipal, fire and police staff) and regional (e.g., provincial environment and forest fire staff) responders, and mutual aid organizations and companies. The records indicated that the company was conducting well-attended, regular, planned exercises with clear program, learning and coordination objectives. Westcoast provided records indicating that over 50 exercises were completed in 2012 and 58 had been completed in 2011. Further, Westcoast has added 100% completion of the EM training and exercise programs to the Short-Term Incentive Pay (STIP) structure. Review of Westcoast records indicated a 100% completion record with the final records for the year indicating staff attending the activities from all regions to assure target completion.

Additionally, review of records associated with the continuing education and awareness programs indicated that Westcoast included post-activity review and learn exercises, which resulted in improvements to company plans, processes and procedures, where required.

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, 33, 34 and 35
CSA Z662-11 Clauses 3.1.2(d), 10.5.2.2 and 10.5.2.3

Assessment:

During document and record review, as well as interviews with staff, Westcoast was not able to demonstrate full compliance with this sub-element.

The company was able to demonstrate that it employs many methods for communicating its EMP with its internal and external stakeholders. Staff are provided information regarding EM as well as Health, Safety and Environment practices in general during induction activities and throughout an employee’s tenure during:

• employee competency training;
• safety meetings;
• EM exercises and drills; and
• routine on-line information practices.

Documents reviewed indicated that two-way communication of EM information was routinely being undertaken between and across all levels of the organization.

EM staff was also able to demonstrate appropriate, on-going communication practices, procedures and activities between Westcoast and its external stakeholders. The stakeholders involved included:

• corporate and private individuals within the various planning zones;
• municipalities;
• responder agencies;
• provincial and federal organizations; and
• mutual aid partners.

In reviewing the stakeholder communication practices the audit found that the practices were documented and, where applicable, included checklists and guidance for staff to ensure that critical information was being provided. Further, EM staff provided records indicating that Westcoast undertakes internal and external effectiveness reviews of its communication and awareness programs and activities. Westcoast staff provided evidence of the formal review of the results of the surveys and the implementation of corrective and preventive actions as well as suggested process improvements which were identified in the records.

Only one non-compliant issue was noted during the Board’s audit of this sub-element. During the review of Westcoast’s gas control notification process used by the public or internal parties to report a potential incident, it was noted that the procedure did not include standardized formal safety messaging to ensure the on-going safety of the caller. Westcoast EM staff agreed that this would result in a better practice and indicated that they would begin the development of an updated practice regardless of this audit and reporting schedule. Although improvements were discussed, at the time of the audit, Westcoast failed to demonstrate the standardized formal safety messaging required.

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 and 32
CSA Z662-11 Clauses 3.1.2(e) and 10.5.2.3

Assessment:

Through document and record review as well as interviews with staff, Westcoast was able to demonstrate compliance with this sub-element with respect to EM.

Westcoast provided copies of its EM manuals, plans and responder handbooks for review. Westcoast has developed appropriate documentation for the communication, development, implementation and management of its EM program and for responding to and managing its potential emergencies.

Westcoast’s EM staff demonstrated processes for ensuring that all critical EM documentation (EM plans, procedures, etc.) was being regularly and formally reviewed, and revised on an on-going basis. EM manuals and plans are kept in electronic format on Westcoast’s internal intranet site and in paper format using controlled documentation practices.

Review of the documentation and associated records indicated that Westcoast has been implementing its document management procedures on an on-going basis.

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:

N/A

Assessment:

By definition, EM controls are considered to be controls for managing and responding to upset or abnormal operating conditions; therefore, the audit results for the entire EM program, including proactive activities and documentation such as training, etc. will be documented in sub-element 3.7 Operational Control-Upset or Abnormal Operating Conditions, below.

Compliance Status: N/A

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 (for example, after emergency events).

References:

OPR-99 Sections 32, 35 and 52
CSA Z662-11 Clauses 3.1.2(e) and 10.5.2

Assessment:

Through document and record review, as well as interviews with staff, Westcoast was able to demonstrate that it has a number of controls for addressing the hazards and risks associated with upset conditions. The primary controls used by Westcoast are the proactive development of its corporate Spectra Energy EM Manual and site specific Spectra Energy Field Emergency Response Plans (FERPs). These documents contain descriptions of the potential incidents and hazards caused by emergencies across Westcoast’s system. These documents also include:

• descriptions of the hazardous products and associated emergency planning zones;
• immediate actions to be taken in the case of an incident;
• the various roles and responsibilities of staff and responders during an incident;
• reporting and communication requirements and information; and
• other information related to the incidents.

Westcoast also provided copies of its First Responder Handbook, which is a focused and condensed version of the EM manual for use by field staff as a resource document in the event of an incident.

Review of the EM manual and FERPs indicated that they were well organized, up-to-date and contained all of the practices associated with each individual hazard. Further, review of the Westcoast facilities including potential hazards, consequences and geographical influences compared against the FERPs, indicated that the individual plans reflected appropriate geographical regionalization and the individual product hazards. This is important as the facilities reviewed include sour and acid gas facilities, as well as sweet gas transmission through populated or urban areas.

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 Z662-11 Clauses 3.1.2(h)(i) & (ii) and 10.5.2.4

Assessment:

Assessment: Through document and record review, as well as interviews with staff, Westcoast was able to demonstrate that the development and implementation of its EM program was being adequately monitored. Westcoast provided records of review by program and senior managers with respect to the development of documents, training and competency, mutual aid agreements, exercises, awareness programs, etc. Westcoast also provided procedures requiring formal evaluations for training, exercises, investigations and responses. Westcoast provided records of the implementation of these procedures. Westcoast also presented records indicating follow-through to close-out of issues requiring changes.

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 Clause 3.1.2(h)(i)

Assessment:

Westcoast was able to demonstrate through document and record review that it has developed and implemented appropriate incident management and investigation processes. Westcoast was also able to demonstrate that it has adequate processes in place to identify, develop and implement corrective and preventive actions that arise from its management or incident investigation processes.

Compliance Status: 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 Z662-11 Clause 3.1.2(e)

Assessment:

Records relating to the EMP were retained in the regional offices in Charlie Lake, BC. Document review confirmed that the company had record retention processes in place that include appropriate types of records to be retained, retention timeframes and disposal methods. All records requested were readily retrieved.

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 Z662-11 Clause 3.1.2(h)(iii)

Assessment:

While the EM manager and other senior staff at Westcoast closely monitor the EM program, the company did not present information indicating that an adequate audit of the EM program, either on a stand-alone basis or in conjunction with either Safety and/or Environmental Protection Program audits, had been completed.

In response to the Draft Audit Report, Westcoast stated that, in 2011, Spectra Audit Services conducted an audit of Crisis Management, and that an internal Operations Assurance review of Emergency Preparedness was conducted in Q4, 2012. During the audit, the information referenced in Westcoast’s response was brought forward by Westcoast’s emergency management staff; however, it was determined that the Crisis Management audit would not meet the Board’s regulatory requirements as it did not measure compliance pursuant to sections 53 and 55 of OPR-99.

Westcoast did demonstrate that it has a number of audit programs applicable to its facilities. These programs were implemented by staff from Calgary, Alberta or in its head office in Houston, Texas. The Board examined these processes and their management, and has determined that they would meet the Board’s requirements if applied to the EM program.

Compliance Status: Non-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 Z662-11 Clause 3.1.2(h)(iii)

Assessment:

Interviews and record reviews indicate that the EM Program undergoes regular review by Westcoast’s senior management starting at the EM Manager through to the president of the company. Westcoast’s senior management also holds meetings on a regular basis at different field locations to evaluate the operations of the individual facilities and to provide leadership at the facility level. Westcoast is demonstrating its management commitment to the EM Program by assigning value to its activities by attaching STIP measures to four of its activities including development and maintenance of FERPs, completion of training and exercise requirements and implementation of the liaison and awareness programs.

While the Board acknowledges the involvement and review of the EM Program by Westcoast senior management, based on the non-compliances identified in sub-element 4.4 Internal Audit, the Board is not satisfied that management review has been undertaken with a view to ensuring the continuing compliance, suitability, adequacy and effectiveness of the EM Program. The Board views compliance with this sub-element to rest with senior management. Further, the Board views the development and implementation of an audit program compliant with sections 53 and 55 of OPR-99 to be a key demonstration of the adequacy of its programs.

Compliance Status: Non-Compliant

Date modified:

2020-09-29