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Appendix I^{Footnote i}

Public Awareness Program Audit Evaluation Table

1.0 POLICY AND COMMITMENT

1.1 Leadership Accountability

Expectations:

The company shall have an accountable officer appointed who has the appropriate authority over the company’s human and financial resources required to establish, implement and maintain its management system and protection programs, and to ensure that the company meets its obligations for safety, security and protection of the environment. The company shall have notified the Board of the identity of the accountable officer within 30 days of the appointment and ensure that the accountable officer submits a signed statement to the Board accepting the responsibilities of their position.

References:

PCR Part II section 4; OPR sections 6.1, 6.2, 40, 47, 48

Assessment:

Accountable Officer

The Board requires the company to appoint an accountable officer. The accountable officer must be given appropriate authority over the company’s human and financial resources for ensuring that the company meets its obligations for safety, security and protection of the environment.

On 10 May 2013, Alliance submitted written notice to the Board indicating that its President and Chief Executive Officer, Terrance Kutryk, had been appointed as the accountable officer for Alliance Pipeline Ltd. The audit team verified that there have been no changes in the accountable officer for Alliance Pipeline Ltd. at the time of the audit. In its submission, Alliance confirmed that its accountable officer has the authority over the human and financial resources required to meet the Board’s substantive expectations.

Summary

Based on the Board’s evaluation of Alliance’s Public Awareness program against the requirements, the Board has determined that Alliance is Compliant with this sub-element.

Compliance Status: Compliant

1.2 Policy and Commitment Statements

Expectations:

The company shall have documented policies and goals intended to ensure activities are conducted in a manner that ensures the safety and security of the public, workers, the pipeline, and protection of property and the environment. The company shall base its management system and protection programs on those policies and goals. The company shall include goals for the prevention of ruptures, liquids and gas releases, fatalities and injuries and for the response to incidents and emergency situations.

The company shall have a policy for the internal reporting of hazards, potential hazards, incidents and near-misses that includes the conditions under which a person who makes a report will be granted immunity from disciplinary action.

The company’s accountable officer shall prepare a policy statement that sets out the company’s commitment to these policies and goals and shall communicate that statement to the company’s employees.

References:

PCR Part II section 4; OPR sections 6.1, 6.3, 40, 47, 48

Assessment:

Policies

Alliance has established corporate policies within its Operational Risk Management System (ORMS). These policies are approved by the Alliance President and Chief Executive Officer (CEO). The ORMS outlines the company’s vision and overarching corporate goal “No safety, pipeline, or environmental incidents” and this is demonstrated by referring to supporting corporate policies such as:

Code of Business Conduct;
Environment Policy;
Health and Safety Policy; and
Security Policy.

The ORMS Policy document also defines the accountability and responsibility with the CEO responsibilities and all employees, contractors and consultants responsibilities described.

The Board has verified that Alliance’s Accountable Officer has prepared a policy statement that sets out Alliance’s commitment to these policies as outlined in the ORMS Policy. The policy statement includes commitments to the protection of people, property, environment and to the use of ORMS. Commitments are made to employee-partners to encourage the reporting of all incidents, hazards, near misses and risks and protecting employee-partners and contractors who report in good faith from any form of retaliation for reporting. The policy is available to all personnel at Alliance through the company intranet. The Board verified through record review and interviews with Alliance representatives that Alliance communicated the ORMS Policy to its employee-partners.

While the ORMS Policy substantially meets the OPR requirements, it does not explicitly refer to the reporting of ‘potential hazards’ as required by the regulations. Review of the supplied information also identified that the Alliance policies did not explicitly identify the conditions under which a person who makes such a report will be granted immunity as part of the reporting policy. The Board notes that the policies are required to be explicit with respect to reporting and what to report in order to, not only encourage reporting but also to clearly identify what to report. Alliance’s statements would require interpretation prior to reporting thus potentially slowing down hazard management and mitigation.

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

Public Awareness Program Policy

The Board reviewed the Health and Safety Policy and verified that it contains content related to emergency response communication, affected public and minimizing risk to the public, which applies to the Public Awareness program. The Board found that Alliance has developed policies and policy statements to meet the requirement of OPR, section 6.3(1) for its programs required by OPR section 55. As the Public Awareness program is subsumed within the Safety Management Program, the Board has determined that Alliance has aligned its Public Awareness program with these policies.

During interviews, Alliance representatives confirmed that, given its role in maintaining public safety, the Public Awareness program aligns with the Health and Safety Policy and that this policy, in addition to others, have been communicated to all Alliance Public Awareness personnel.

Summary

The Board found that Alliance has developed policies and policy statements to meet the requirement of OPR, section 6.3(1).

The Board found that Alliance has based its management system and public awareness program on these policies.

The Board also found the following areas of non-compliance in the Policy and Commitment Statements sub-element:

Alliance did not demonstrate that it has a policy that explicitly describes internal reporting of potential hazards as required by OPR, section 6.3(1)(a); and
Alliance did not demonstrate that its policy includes the conditions under which a person who reports a hazard, potential hazard, incident or near-miss will be granted immunity from disciplinary action as required by OPR, section 6.3(1)(a);

Based on the Board’s evaluation of Alliance’s Public Awareness program against the requirements, the Board has determined that Alliance is Non-Compliant with this sub-element. Alliance will have to develop corrective actions to address the described deficiencies.

Compliance Status: Non-Compliant

2.0 PLANNING

2.1 Hazard Identification, Risk Assessment and Control^{Footnote 1}

Expectations:

The company shall have an established, implemented and effective process for identifying and analyzing all hazards and potential hazards. The company shall establish and maintain an inventory of hazards and potential hazards. The company shall have an established, implemented and effective process for evaluating the risks associated with these hazards, including the risks related to normal and abnormal operating conditions. As part of its formal risk assessment, a company shall keep records to demonstrate the implementation of the hazard identification and risk assessment processes.

The company shall have an established, implemented and effective process for the internal reporting of hazards, potential hazards, incidents and near-misses, and for taking corrective and preventive actions, including the steps to manage imminent hazards. The company shall have and maintain a data management system for monitoring and analyzing the trends in hazards, incidents, and near-misses.

The company shall have an established, implemented and effective process for developing and implementing controls to prevent, manage and mitigate the identified hazards and risks. The company shall communicate those controls to anyone exposed to the risks.

References:

PCR Part II section 4, OPR sections 6.1, 6.5(1)(c),(d),(e),(f),(r),(s), 40, 47, 48

Assessment:

The Board expects companies to have an established, implemented and effective process for identifying and analyzing all hazards and potential hazards.

Identifying, Analyzing and Evaluating Hazards

The Board verified that Alliance performs a number of activities along its rights-of-way (ROW) related to the identification of hazards and potential hazards for the Public Awareness program. These activities include monthly aerial patrols, ROW monitoring and identification of potential new developments or points of interest (POI) such as new land development.

The Board confirmed that Alliance does have a process in place to analyze all known hazards related to third party activity in order to determine an appropriate Public Awareness program response. However, the Board could not verify that Alliance has implemented a process to add and evaluate new hazards and potential hazards. For example, Alliance did not demonstrate that all of the hazards posed by third parties working around its facilities were identified from unauthorized activity reports. The Board also verified that Alliance does not identify and track other potential hazards to the Public Awareness program other than POIs such as any trends for third party activity identified from requests for permission.

Alliance demonstrated that the Land, Right of Way and Corridor Management (LRCM) team enters identified hazards and potential hazards into a company database. Interviews confirmed that the Alliance Pipeline Risk Management and Program Development (PRMPD) engineering team reviews the threats recorded in the database and, annually, develops a threat/hazard identification and assessment report. The Board verified that the report includes a review of threats from external interference that include first, second, third parties, vandalism and other. Although this study has both qualitative and quantitative aspects, the Board found that these aspects are not fully explored. For example, the study indicates that there were no threats in the “other threats” category. Therefore it is unclear how this report accounts for the potential that third parties such as the public, or excavation contractors not associated with Alliance could damage the pipeline as a result of not knowing the location of the buried facilities. During interviews, LRCM management indicated that it reviews this PRMPD assessment and its recommendations to identify if changes are warranted. However, the Board did not identify that any changes to the inventory or amendments to existing practices to reflect continual improvement.

In addition, the Board did not see an evaluation of hazards and risk assessment for abnormal operating conditions nor any evidence that the identified hazards were analyzed to determine the root causes, potential consequences, and or likelihood for both normal and abnormal operating conditions.

Based on the interviews and documents reviewed, the Board determined that Alliance has implemented a practice to identify, analyze and evaluate some of the hazards to be addressed by its Public Awareness program by reviewing internal reports and typical activities. However, Alliance could not demonstrate that it had a process to identify, evaluate and analyze hazards from other sources such as reported unauthorized activities, municipal developments or trends in third party requests for permission.

Hazard Inventory and Risk Assessment

The Board expects companies to establish and maintain an inventory of hazards and potential hazards. In addition, the Board expects companies to have an established, implemented and effective process for evaluating the risks associated with these hazards.

The Threat/Hazard Identification and Assessment includes a list of hazards such as mechanical damage by third parties and vandalism. It also includes issues that could undermine the success of the program such as landowner fatigue with respect to the public awareness activities and the scheduling of activities and mail-outs is based on knowledge and consideration of seasonal land maintenance activities.

Third party activities conducted without company permission as required by the PCR are considered unauthorized activities. These activities can be an indicator of activities or groups of stakeholders that should be addressed through the Public Awareness program. At the time of the audit, interviews confirmed that although the LRCM group discusses trends noted in reported unauthorized activities, as indicated above, there is not a process to ensure that these real-time hazards associated third party activity along the ROW are evaluated for incorporation into the Public Awareness program. Instead, the Public Awareness program works from a mostly static list of typical hazards associated with activities on land adjacent to rights of way.

For the reasons noted above, the Board is of the view that the list does not constitute an exhaustive list of hazards that corresponds to those risks identified through unauthorized activities. During its review, the Board noted several examples of hazards that have not been incorporated into the hazard inventory for the Public Awareness programs such as excavators, landowner turnover, urban encroachment and seismic activity. Therefore, the list of hazards was incomplete.

Control

The Board confirmed that the role of Alliance’s Public Awareness program is to establish and implement appropriate controls to address the hazards presented by third parties working around its facilities. Interviews with Alliance staff and review of the Public Awareness program indicated that Alliance has developed and implemented controls to manage the identified hazards. For example, in order to address the hazards associated with seasonal land maintenance activities, Alliance schedules its awareness activities and mail-outs for the Spring to coincide with the planning of such activities.

Summary

The Board has found that Alliance has established and implemented a practice for the identification of some hazards and potential hazards that applies to its Public Awareness program. However, the Board could not verify that Alliance has implemented a process to add and evaluate new hazards or potential hazards.

The Board found that Alliance did not demonstrate that it has established and maintained an inventory of all hazards and potential hazards introduced by third parties.

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

Compliance Status: Non-Compliant

2.2 Legal Requirements

Expectations:

The company shall have an established, implemented and effective process for identifying and monitoring compliance with all legal requirements that are applicable to the company in matters of safety, security and protection of the environment. The company shall have and maintain a list of those legal requirements. The company shall have a documented process to identify and resolve non-compliances as they relate to legal requirements, which includes updating the management and protection programs as required.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(g),(h),(i), 40, 47, 48

Assessment:

The Board requires that companies have a process for identifying and monitoring compliance with all legal requirements and to maintain a list of these requirements.

Identifying and Monitoring Compliance

As part of its demonstration, Alliance pointed the Board to their centralized compliance management system (CCMS) and the systems supporting documentation as their established and implemented documented process for identifying legal requirements. Upon review, the Board determined that these documents do not include the steps to how the legal requirements were identified but focused on how to use the CCMS. As a result, Alliance was unable to demonstrate that it has established and implemented a documented process to identify all legal requirements applicable to the company. The Board notes that while a management system process deficiency currently exists, the Board did confirm through interviews with Alliance representatives that Alliance, with the support of a third party provider and internal subject matter expertise, did identify legal requirements that, in the opinion of Alliance, are applicable to the company. Please refer to the Legal List below for additional details.

Similar to above, Alliance pointed to its CCMS documentation in order to demonstrate that it has established and implemented a process for monitoring compliance with its applicable legal requirements. Upon review, this documentation is focused on monitoring changes to legal requirements. While monitoring changes to legal requirements is one aspect of monitoring compliance and is required to be accounted for in the OPR’s management of change process, the Board notes that this is a reactive approach and does not proactively ensure that Alliance is in compliance with its current legal requirements (see Sub-element 4.1 Inspection, Measuring and Monitoring for additional details). The Board notes that while a process deficiency currently exists, the Board did confirm through interviews with Alliance representatives and documentation review that Alliance is monitoring compliance with applicable legal requirments through several Public Awareness program level practices.

Legal List

As noted earlier, Alliance has developed a centralized electronic library, CCMS, in order to the meet the Board’s requirements to maintain a legal list. During the audit, Alliance provided several demonstrations of this system and how it will be utilized to ensure Alliance remains in compliance with applicable legal requirements through various processes, procedures and practices. The Board verified that Alliance has established and maintained a legal list that includes all applicable federal and provincial requirements for the various protection programs included in this audit.

However, Alliance’s legal list does not include referenced standards, with the most notable omission being the Canadian Standards Association (CSA) library of standards. During interviews, Alliance indicated that it is barred from incorporating any CSA standards content into its legal list due to CSA copyright restrictions. While the Board agrees that copyright restrictions may exist, it should not limit Alliance from listing the clause numbers of the specific provisions and not the actual text of the provisions. This alternative was discussed with Alliance during the audit with Alliance indicating that this would be unworkable for the following reasons:

Reliability and Usage Considerations – Since the purpose is ultimately to ensure compliance, the legal list must be easy to use and maintain. And above all else, it must be reliable. In order to achieve these ends, Alliance is of the view that the actual text of the requirements must be set out explicitly. If users are required to continually cross-reference the source document against the clause numbers, errors will inevitably result, rendering the list unreliable and possibly even creating a greater risk of non-compliance.
Additional Challenges of Cross-Referencing – The need to continually cross-reference would make auditing against the requirements much more difficult and also raise challenges in terms of keeping the list current.
Administrative Burden – Alliance secured the services of a third party provider to extract the legal requirements from the source document and enter them into their system on Alliance’s behalf. In this case, copyright restrictions bar Alliance from disclosing CSA standards to their third party provider. Alliance would therefore have to bear the administrative burden of extracting the clause numbers that are associated with the legal requirements.

Alliance also indicated that “it does not see any practical merit in replicating the voluminous content of consensus standards in a legal list” as company personnel have access to the standards and are fully cognizant on how these standards apply to the respective areas.

The Board agrees that the copyright restrictions may present a barrier from a development and maintenance perspective. However, it’s the Board opinion that having these applicable clauses listed, albeit in an abbreviation aspect, would achieve a higher probability of compliance versus relying solely on the company’s subject matter expertise. As a result, the Board has determined that Alliance has not demonstrated a legal list that the meets the requirements of the Board.

Communicating Legal Requirements

Alliance was able to demonstrate that it communicates legal requirements related to living and working safely around its facilities through its external website and Public Awareness program material. Alliance also demonstrated that it was communicating legal requirements such as administrative monetary penalties to third parties. Internally, interviews with staff confirmed that regulatory updates are discussed during the weekly team meetings and posted on the internal intranet.

Summary

The Board found that Alliance demonstrated that it was tracking, listing and communicating some of its legal requirements related to the Public Awareness program.

The Board found that Alliance had developed and implemented practices to communicate the legal requirements internally and with third parties Also, Alliance demonstrated that it was communicating new or revised legal requirements to third-parties through its Public Awareness program.

The Board also found that Alliance’s methods to monitor its legal requirements and compliance to them did not meet the Board’s requirements.

The Board found that Alliance’s legal list was not kept at the level of specificity required to enable the company to ensure and monitor its compliance with the legal requirements.

Compliance Status: Non-Compliant

2.3 Goals, Objectives and Targets

Expectations:

The company shall have an established, implemented and effective process for developing and setting goals, objectives and specific targets relevant to the risks and hazards associated with the company’s facilities and activities (i.e., construction, operation and maintenance). The company’s process for setting objectives and specific targets shall ensure that the objectives and targets are those required to achieve its goals, and shall ensure that the objectives and targets are reviewed annually.

The company shall include goals for the prevention of ruptures, liquid and gas releases, fatalities and injuries, and for the response to incidents and emergency situations. The company’s goals shall be communicated to employees.

The company shall develop performance measures for assessing the company’s success in achieving its goals, objectives, and targets. The company shall annually review its performance in achieving its goals, objectives and targets and the performance of its management system. The company shall document the annual review of its performance, including the actions taken during the year to correct any deficiencies identified in its quality assurance program, in an annual report, signed by the accountable officer.

References:

PCR Part II section 4, OPR sections 6.1, 6.3, 6.5(1)(a),(b), 6.6, 40, 47, 48

Assessment:

Goals, Objectives and Targets

The Board requires the company to document its policies and goals for ensuring its activities are conducted in a manner that ensures the safety and security of the public, workers and pipeline, and the protection of property and the environment. Through interviews and documentation review, Alliance demonstrated its senior leadership team has developed goals to meet the obligations referred to above. These goals are reviewed and reported upon during the quarterly and annual management review meetings.

In addition, the OPR specifically requires goals for the following:

Prevention of ruptures;
Prevention of liquid and gas releases;
Prevention of fatalities and injuries; and
Response to incidents and emergency situations.

While Alliance has established documented goals for the prevention of ruptures, fatalities and injuries, its documented goals for the prevention of liquid and gas releases is limited to its pipeline right-of-way and does not include its aboveground facilities. As for goals for the response to incidents and emergency situations, Alliance did not develop a specific goal other than to track whether it had to respond to an incident or emergency situations. The Board expects that goals for these types of events should include, but not limited to, incident response times. For the Public Awareness program, Alliance had developed goals and targets relating to emergency situations.

As demonstrated in its annual Accountable Officer Report, Alliance has established strategic management goals, objectives, performance measures and targets that are reviewed annually under the LRCM Annual Program Review Practice. At the time of the audit, the Board found that Alliance’s Public Awareness Program had goals and objectives that were in line with the corporate goals, however, no documented evidence was provided as to how these objectives are set and how often they are reviewed for appropriateness. For the Public Awareness program, one of these objectives related to the corporate goal of zero leaks or ruptures is that “excavators are informed of their obligations with respect to worth within the Alliance easement or the pipeline Safety Zone”. The Board determined that Alliance’s LRCM develops an annual tactical plan that includes performance targets related to the Public Awareness program. For example, Alliance has a target that it will conduct face to face visits with all of its landowners on a four year rotation. Also, as discussed in sub-element 3.1 of this report, Alliance has not implemented a process to evaluate the effectiveness of its method for informing excavators; therefore it is unclear how this goal is measured.

The Public Awareness program sets goals for the program related to its operational deliverables such as number of landowners visited, the number of emergency responder contacts made and number of awareness and emergency management events attended. On a corporate level, Alliance ties personal performance to program goals through accountability agreements and these agreements show the line of site from corporate to team to individual goals.

The Board found that Alliance’s Public Awareness program includes requirements to perform surveys with its affected public, emergency officials and local public officials in an effort to examine their effectiveness and for continual improvement. The results of the survey study will inform the performance measurers in achieving their objectives. At the time of the audit the survey study had not been completed, as a result the Board is unable to assess at this time. Where concerns were raised from the surveys received to date, those specific singular issues were addressed with the stakeholder.

Summary

The Board found that Alliance has developed Public Awareness program goals, objectives, and targets related to program outputs and activities planned versus attended.

The Board found that Alliance has developed goals for the prevention of ruptures, fatalities and injuries but has not developed goals for the response to incidents and emergency situations. The Board also found that Alliance’s goals for the prevention of liquid and gas releases are limited to its pipeline right-of-way and do not include its aboveground facilities.

The Board also found that Alliance has established a goal for informing third parties but was unable to demonstrate how the Public Awareness program is tied to the achievement of that goal.

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

Compliance Status: Non-Compliant

2.4 Organizational Structure, Roles and Responsibilities

Expectations:

The company shall have a documented organizational structure that enables it to meet the requirements of its management system and its obligations to carry out activities in a manner that ensures the safety and security of the public, company employees and the pipeline, and protection of property and the environment. The documented structure shall enable the company to determine and communicate the roles, responsibilities and authority of the officers and employees at all levels. The company shall document contractors’ responsibilities in its construction and maintenance safety manuals.

The documented organizational structure shall also enable the company to demonstrate that the human resources allocated to establishing, implementing and maintaining the management system are sufficient to meet the requirements of the management system and to meet the company’s obligations to design, construct, operate or abandon its facilities to ensure the safety and security of the public and the company’s employees, and the protection of property and the environment. The company shall complete an annual documented evaluation in order to demonstrate adequate human resourcing to meet these obligations.

References:

PCR Part II section 4; OPR sections 6.1, 6.4, 20, 31, 40, 47, 48

Assessment:

The Board expects companies to have a documented organizational structure that enables them to meet the requirements of their obligations to carry out activities in a manner that ensures the safety and security of the public, company employees and the pipeline, and protection of property and the environment.

Organizational Structure

The Board verified that Alliance provided documents and records that demonstrated it had established and maintained documented roles and responsibilities statements related to its Public Awareness program and activities that applied to all levels within the organization as well as contractors. Alliance’s Public Awareness, Crossing and Damage Prevention programs are managed by the LRCM group and the field staff report to their respective Area Managers.

Annual Evaluation of Resource Need

Along with a documented organizational structure, the Board expects companies to demonstrate an ongoing ability to sustain its program. The Board requires that companies demonstrate, based on an annual documented evaluation of need, that the human resources required to establish, implement and maintain the programs are sufficient to meet operational and regulatory requirements.

Alliance demonstrated that it has developed a number of corporately required or supported mechanisms for evaluating its resourcing needs, including quarterly and annual meetings, progress reports and work completion reports. In addition, Alliance provided the Board a document entitled Corporate Procedure / Assessment of Need Process which explains the process that Alliance has undergone during 2013 and 2014 to assess and rationalize its resource needs and shape its new organizational design. To demonstrate implementation of this process, Alliance also provided a document entitled Corporate Procedure / Assessment of Need Process – Findings that provided the essential results of the assessment undertaken during 2013 and 2014. Upon review of these records, the Board found that Alliance has not demonstrated an annual documented evaluation of need that meets the Board’s requirements as these records were exception based and thus the Board could not attest to the comprehensiveness of this review.

For the Public Awareness program, Alliance did not demonstrate that it conducts an evaluation of need that includes the resources required for the maintenance and continual improvement of the management system. During head office and field interviews, Alliance indicated that it uses Land, Right-of-Way, and Community Representatives and contractors to conduct the face-to-face visits, on-demand sessions and unauthorized activity follow-up that are part of the Public Awareness program. The Board was advised that each employee-partner within the LRCM team wears multiple hats. The Board identified issues related to staffing levels and insufficient resources required to implement the program based on the volume of work and number of hours each employee-partner was working in order to conduct all of the program activities. As Alliance moves forward it will need to consider the human resources required for the maintenance and continual improvement of its management system as well as the implementation of any identified corrective actions.

Summary

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

The Board found that Alliance has not established or implemented mechanisms for reviewing it Public Awareness program workforce needs. Therefore, Alliance could not demonstrate that the human resources allocated to its Public Awareness program are sufficient in meeting its requirements.

Compliance Status: Non-Compliant

3.0 IMPLEMENTATION

3.1 Operational Control-Normal Operations

Expectations:

The company shall have an established, implemented and effective process for developing and implementing corrective, mitigative, preventive and protective controls associated with the hazards and risks identified in elements 2.0 and 3.0, and for communicating these controls to anyone who is exposed to the risks.

The company shall have an established, implemented and effective process for coordinating, controlling and managing the operational activities of employees and other people working with or on behalf of the company.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(e),(f),(q), 40, 47, 48

Assessment:

The Board requires that regulated companies have an established, implemented and effective process for developing and implementing corrective, mitigative, preventive and protective controls associated with the hazards and risks identified in elements 2.0 and 3.0, and for communicating these controls to anyone who is exposed to the risks.

Development of Controls

Interviews indicated that Alliance’s Public Awareness program was developed and implemented to inform external stakeholders about the safe work around pipelines as well as what to do in case of emergency. Alliance’s Damage Prevention and Land, Right of Way and Corridor Management documents outline the overall goals, strategies and tactics for the Public Awareness program.

Interviews with Alliance personnel indicated communication to stakeholders was a key control mechanism for Alliance’s Public Awareness program and hence has well established communication methods. In order to ensure that its external stakeholders receive consistent awareness material, Alliance delivers a large part of its awareness material through mail-outs managed out of the Head Office according to the following schedule:

landowner face-to-face visits once every 4 years;
affected public is to be contacted at least once every 2 years through the distribution of an awareness package with all relevant baseline messages;
excavators who have conducted an unauthorized activity in the previous 5 years are to be contacted once every year;
emergency officials are to be contacted once a year; and
public officials are to be contacted once every three years.

Alliance staff indicated that there have been no documented or informal changes to the Public Awareness program materials or outreach activities since 2012.

Alliance staff provides awareness to landowners during face to face visits and project related meetings. During these visits, Alliance representatives address:

how to reduce the likelihood of accidental damage to the pipeline;
awareness of the NEB requirements when working around pipelines;
accuracy of the contact information and whether or not there is a tenant situation;
awareness of the presence of the pipeline; and
awareness of One-Call and that they should call them prior to performing any excavation work.

While Alliance has a number of outreach strategies and activities, document review indicated that the plans, tactics and strategies outlined did not correspond to all of the hazards listed therefore leaving some unmitigated. For example, Alliance has identified vandalism as a threat however no evidence was provided to control or mitigate this threat.

The audit further determined that Alliance did not demonstrate that it has implemented a process to determine that its mitigation strategies correspond to the appropriate level of control for each of the hazards listed. For example the LRCM objectives state that “Excavators are informed of their obligations with respect to work within the Alliance easement or the pipeline Safety Zone”. Yet when asked to discuss its strategy for informing excavators, Alliance stated that it relies on industry safety shows, unauthorized activity follow-up, and safety information sent once they have already requested permission to inform excavators of their obligations. Through a review of documentation and records, Alliance did not provide any analysis to demonstrate that these controls are adequate and that the chosen mitigation strategy for this hazard was effective; therefore the Board has determined that Alliance has not evaluated this control to determine its ongoing effectiveness.

For its Public Awareness program, the Board found that Alliance has developed and implemented various controls such as face to face visits, participation in safety organizations and targeted mail-outs. However, Alliance could not demonstrate that it had evaluated the effectiveness of its controls in mitigating all of the hazards presented by third party activity near its facilities.

Summary

Although Alliance demonstrated that it has established controls for the hazards in its Public Awareness program, it did not demonstrate that it has a process in place to evaluate the effectiveness of its controls.

Compliance Status: Non-Compliant

3.2 Operational Control-Upset or Abnormal Operating Conditions

Expectations:

The company shall establish and maintain plans and procedures to identify the potential for upset or abnormal operating conditions, accidental releases, incidents and emergency situations. The company shall also define proposed responses to these events and prevent and mitigate the likely consequence and/or impacts of these events. The procedures must be periodically tested and reviewed, and revised where appropriate (for example, after upset or abnormal events). The company shall have an established, implemented and effective process for developing contingency plans for abnormal events that may occur during construction, operation, maintenance, abandonment or emergency situations.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(c),(d),(e),(f),(t), 32, 40, 47, 48

Assessment:

Upset or Abnormal Operating Conditions

The Board verified that the Alliance Emergency Management program has responsibilities for establishing operating controls for incident response and has documented its planning requirements and procedures in its Emergency Response Plans, Contractor Safety Manual and within its site-specific response plans. Alliance’s Public Awareness program has defined responsibilities related to the development and maintenance of activities, which support the ongoing education of stakeholders including first responders and performs engagement activities, mail-outs and data to inform external stakeholders of potential emergency situations.

The Board found that Alliance’s Public Awareness program staff participated in the development and delivery of emergency management related training material for first responders and pipeline neighbors. Alliance demonstrated through interviews and training records reviewed that its public awareness personnel involved in communication activities are also trained in the Incident Command System (ICS).

The Board reviewed information that demonstrated that Alliance had included emergency information, such as the signs of a potential leak and the identification of potential emergency events, in the safety information within its mail-outs. During the face to face visits, Alliance representatives confirm resident information to maintain the accuracy of the Alliance database system for the affected public, which is to be used to generate lists to be used in the event of an emergency.

Contingency Plans

Under the OPR, companies are required to establish and implement a process for developing contingency plans for abnormal events that may occur during construction, operation, maintenance and abandonment activities. The Public Awareness program is directly linked to the Emergency Management program that is being concurrently audited with this program. The audit identified that Alliance did not have an established and implemented program level process for developing contingency plans as required by the OPR. As the Board has made a non-compliant finding in that audit which will cause a corrective action plan that addresses this program deficiency to be developed, the Board will not assign further non-compliance in the sub-element. Alliance’s corrective action plan developed to address that finding must specifically and explicitly include actions to address this program’s deficiency.

Summary

The Board found that Alliance demonstrated that its Public Awareness staff plays a role in supporting the Emergency Response program. Alliance leveraged its public awareness mail-outs and outreach activities to support its emergency response capabilities and regulatory requirements.

The Board found that Alliance’s Public Awareness staff that have responsibilities during an emergency are appropriately trained.

The Board found that Alliance does not have a process for developing contingency plans for abnormal events that may occur during construction, operation, maintenance and abandonment activities; however, this non-compliance is addressed within its concurrent Emergency Management program and a further Non-compliant finding will not be made in this sub-element. In order to ensure that related issues are addressed for this program, Alliance’s corrective action plan must specifically and explicitly consider actions to resolve this program’s deficiency.

Based on the Board’s evaluation of Alliance’s Public Awareness program against the requirements, the Board has determined that Alliance is Compliant with this sub-element.

Compliance Status: Non-Compliant

3.3 Management of Change

Expectations:

The company shall have an established, implemented and effective process for identifying and managing any change that could affect safety, security or protection of the environment, including any new hazard or risk, any change in a design, specification, standard or procedure and any change in the company’s organizational structure or the legal requirements applicable to the company.

References:

PCR Part II section 4; OPR sections 6,1, 6.5(1)(i), 40, 47, 48

Assessment:

During the audit, Alliance demonstrated that it has developed several standards, procedures, and processes for managing change as described as follows:

Operational Excellence Management System Standard – Management of Change – describes the key components required to be included in the protection program management of change (MOC) practice;
Management of Change for Legal Requirements in CCMS – describes how changes to legal requirements are accounted for; and
Field Operations MOC Process – describes how changes at the operational level (i.e. changes to assets, procedures, etc.) are assessed.

In addition, and as listed in its ORMS framework provided to the Board, Alliance has indicated that it will be developing a Corporate Management of Change process that is still being formalized.

Based on documentation review and interviews, the Board has determined that Alliance has not met the requirements of OPR, section 6.5(i) for the following reasons:

The aforementioned standards, procedures and processes function independently of one another and thus are not systematic;
Changes to organizational structure are not accounted for in these standards, procedures and processes.
While the Field Operations MOC Process is adequately designed, Alliance could not demonstrate that it is being consistently implemented as prescribed.
As one example, the process requires that environmental checklists are to be completed for every asset based change. Records reviewed during the audit did not contain these checklists.

The Board notes that the OPR requires a company to develop a management system MOC process that identifies and manages any change that could affect safety, security or the protection of the environment. Further the Board notes that, while a company may have multiple processes, there still must be consistency in process requirements, development and implementation as well as coordination of the various practices in order to meet the OPR requirements and to ensure formal management.

Summary

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

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

Compliance Status: Non-Compliant

3.4 Training, Competence and Evaluation

Expectations:

The company shall have an established, implemented and effective process for developing competency requirements and training programs that provide employees and other persons working with or on behalf of the company with the training that will enable them to perform their duties in a manner that is safe, ensures the security of the pipeline and protects the environment.

The company shall have an established, implemented and effective process for verifying that employees and other persons working with or on behalf of the company are trained and competent, and for supervising them to ensure that they perform their duties in a manner that is safe, ensures the security of the pipeline and protects the environment. The company shall have an established, implemented and effective process for making employees and other persons working with or on behalf of the company aware of their responsibilities in relation to the processes and procedures required by the management system or the company’s protection programs.

The company shall have an established, implemented and effective process for generating and managing training documents and records.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(j),(k),(l),(p), 40, 47, 48

Assessment:

The Board expects regulated companies to have an established, implemented and effective process for developing competency requirements and training programs that provide employees and other persons working with or on behalf of the company with the training that will enable them to perform their duties in a manner that is safe, ensures the security of the pipeline and protects the environment.

Developing Competency Requirements and Training Programs

Alliance has developed a Learning and Development Management System that applies to the entire Alliance organization and consists of the following five programs: Onboarding, Training, Competency, Performance Support and Leadership. To administer training and competency evaluation, Alliance utilizes an additional system referred to as the Online Learning Environment (OLE). The system provides the mechanism to register, deliver, track and record learning completions. The OLE also contains requirements for onboarding, training and operations competency that includes skills, knowledge and attributes that an employee-partner needs in order to be considered qualified or capable of performing a specific task. Supporting OLE is an Alliance Competency Evaluation (ACE) program and competency evaluation process that is intended to ensure field maintenance technicians are trained and competent to perform their daily tasks in a safe and effective manner.

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

Alliance has not established and implemented a process for developing competencies and training programs as required by the OPR;
Alliance has developed a training program, including a Training Matrix, that applies to all Alliance personnel, which meets the requirements of OPR, section 46 ;
Through the ACE program, Alliance has developed competencies for its field maintenance technicians. However, this is limited to matters of safety. While the Board recognizes this importance, competencies should also be developed for those tasks that involve public awareness considerations;
The ACE program only accounts for field maintenance technicians and does not include Public Awareness personnel; and
OLE programs apply to Alliance employees but not to all workers doing activities on behalf of the company. Alliance does manage contractors through a third party prequalification process and a field orientation course. However, this is not accounted for by a management system process.

Through interviews and documentation review, Alliance pointed to numerous mechanisms, such as job descriptions and pre-job meetings, for communication of responsibilities. However, Alliance could not demonstrate that it has established and implemented a documented process that makes employees and other persons working with or on behalf of the company aware of their responsibilities.

Managing Training Records

Through a sampling of records across the organization, the Board verified that training records for the Public Awareness program are managed in the OLE training system and are managed by the Learning and Development Team.

Summary

The Board has found that Alliance has not established and implemented a Public Awareness program process for developing competencies and training programs.

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

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

The Board has also found that Alliance has not established and implemented a Public Awareness program process to make employees and other persons working with or on behalf of the company aware of their responsibilities.

Compliance Status: Non-Compliant

3.5 Communication

Expectations:

The company shall have an established, implemented and effective process for the internal and external communication of information relating to safety, security and environmental protection. The process should include procedures for communication with the public, company employees, contractors, regulatory agencies and emergency responders.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(m), 40, 47, 48

Assessment:

The Board expects that companies have established, implemented and effective process for the external communication of information relating to safety, security and environmental protection. The process should include procedures for communication with the public, company employees, contractors, regulatory agencies and emergency responders. The NEB Pipeline Crossing Regulation, Part II (PCR) requires:

4. (1) Every pipeline company shall establish an ongoing public awareness program to inform the public of
1. (a) the presence of the pipeline; and
2. (b) the public’s responsibilities regarding any construction or installation of a facility and any excavation that might affect the pipeline.

External Communication

The Board found that Alliance utilizes its external website to communicate safety, crossings and emergency policy and contact information. Interviews with Alliance confirmed that the LRCM team assists the communication team to ensure the messaging on the external website is updated. The Board verified that Alliance has established several processes for communication with external stakeholders including web based practices and requires an Alliance representative to be onsite for any excavation and involvement with local One-Call organizations and area Common Ground Alliances.

During the audit, Alliance indicated that communicating safety and awareness information with the public and external stakeholders is a main function of the Public Awareness program. Alliance defined its stakeholder audience as affected public, emergency officials, local public officials, and excavators. To maintain communication with the public and its stakeholders Alliance demonstrated that it conducted several activities to inform its external stakeholders. These activities included:participating in exhibits at trade and agriculture shows;

collaborating in cooperative group initiatives;
participating in regional and national common ground alliances associations;
regular mail-outs;
conducting awareness sessions with various stakeholder groups;
providing information on the Alliance website;
answering questions that come into the Public Awareness inbox and hotline;
the development and delivery of training and related materials for first responders; and
face to face visits conducted with residents along the ROW and within 800 m.

The Board examined documents and records that demonstrated that Alliance was delivering the program consistently and was taking into consideration the seasonality of the various potentially hazardous activities that could create a hazard to people or the pipeline. For example, Alliance had developed and implemented a mail-out schedule that coincides with potential seasonal activities such as seeding and spring land maintenance in order to have its awareness materials to serve as timely reminders for the stakeholders.

Internal Communication

The Board found that, at the department level, Alliance demonstrated that it has a documented communication plan that supports the effective implementation and operation of the safety and loss management system as required.

The Board found that Alliance was able to demonstrate that there was formal internal communication occurring. The Board review of records identified that there were regular meetings occurring where internal initiatives were discussed and meeting minutes taken, internal announcements regarding regulatory changes posted on Alliance’s intranet site, weekly team meetings, and an internal SharePoint site is utilized.

Summary

The Board found that Alliance had established and implemented external communication practices applicable to its Public Awareness program that identified the appropriate stakeholders and developed messages relating to maintaining the safety and security of the pipeline and protection of the environment.

The Board found that Alliance had been communicating internally and had developed a communication plan that met the Board’s requirements.

Based on the Board’s evaluation of Alliance’s Public Awareness program against the requirements, the Board has determined that Alliance is Compliant with this sub-element.

Compliance Status: Compliant

3.6 Documentation and Document Control

Expectations:

The company shall have an established, implemented and effective process for identifying the documents required for the company to meet its obligations to conduct activities in a manner that ensures the safety and security of the public, company employees and the pipeline, and protection of property and the environment. The documents shall include all of the processes and procedures required as part of the company’s management system.

The company shall have an established, implemented and effective process for preparing, reviewing, revising and controlling documents, including a process for obtaining approval of the documents by the appropriate authority. The documentation should be reviewed and revised at regular and planned intervals.

Documents shall be revised where changes are required as a result of legal requirements. Documents should be revised immediately where changes may result in significant negative consequences.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(i)(n)(o), 6.5(3), 40, 47, 48

Assessment:

As part of its demonstration, Alliance pointed the Board to their CCMS and the systems supporting documentation as its established and implemented process for identifying the documents required for the company to meet its obligations under OPR, section 6. Upon review, the Board determined that these documents do not include the steps to determine what types of documents are required but focuses on how to use the CCMS. As a result, Alliance was unable to demonstrate that it has established and implemented a Public Awareness program process to meet the requirements of OPR. The Board notes that while a process deficiency currently exists, the Board did confirm through documentation review that Alliance has developed documents that would typically be expected for a company of its size and to the scope, nature and complexity of its activities.

Through its Managing Controlled Documents Procedure, Alliance demonstrated that it has established and implemented a process for the preparing, reviewing, revising and controlling documents including a process for obtaining approval of its documents for the Public Awareness program. In addition and mentioned previously in this report, Alliance has developed a Technical Document Hierarchy that defines the type of documents that can be created within Alliance’s organization. The Board notes that these definitions align with the Board requirements.

Despite the assessment mentioned above, the Board did find a deficiency with Alliance’s process for reviewing documents. While Alliance’s process does stipulate that the reviews of documents are to occur, it does not define a revision schedule. The Board notes that all documents provided during the audit were current based on normal, acceptable industry best practices. However, to ensure that documents remain current in the future, the Board requires that a defined revision schedule be incorporated into this process.

Summary

The Board found that Alliance had established and implemented a Public Awareness program process for preparing, reviewing, revising and controlling its documents. However, this process does not include defined revision schedules for its documents.

The Board also found that Alliance had not established and implemented a Public Awareness program process for identifying the documents required for the company to meet its obligations under OPR section 6.

The Board found that Alliance has developed documents that would be typically expected for a company of its size and to the scope, nature and complexity of its activities.

Compliance Status: Non-Compliant

4.0 CHECKING AND CORRECTIVE ACTION

4.1 Inspection, Measurement and Monitoring

Expectations:

The company shall have an established, implemented and effective process for inspecting and monitoring the company’s activities and facilities to evaluate the adequacy and effectiveness of the protection programs and for taking corrective and preventive actions if deficiencies are identified. The evaluation shall include compliance with legal requirements.

The company shall have an established, implemented and effective process for evaluating the adequacy and effectiveness of the company’s management system, and for monitoring, measuring and documenting the company’s performance in meeting its obligations to perform its activities in a manner that ensures the safety and security of the public, company employees and the pipeline, and protection of property and the environment.

The company shall have an established, maintained and effective data management system for monitoring and analyzing the trends in hazards, incidents and near-misses. The company shall have documentation and records resulting from the inspection and monitoring activities for its programs.

The company management system shall ensure coordination between its protection programs, and the company should integrate the results of its inspection and monitoring activities with other data in its hazard identification and analysis, risk assessments, performance measures and annual management reviews, to ensure continual improvement in meeting the company’s obligations for safety, security and protection of the environment.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(g),(s),(u),(v), 40, 47, 48

Assessment:

The Board expects companies to have an established, implemented and effective process for inspecting and monitoring the company’s activities and facilities to evaluate the adequacy and effectiveness of the protection programs. The NEB PCR, Part II Section 4(2) requires that “Every pipeline company shall assess the effectiveness of its public awareness program on a regular basis and shall maintain a record of the assessment”.

Measurement and Monitoring

During the interviews and document review the Board found that Alliance was measuring the implementation of its Public Awareness program activities. For example the Stakeholder Consultation and Engagement Coordinator ensures the number of face to face visits and mail outs are done according to the approved annual tactical plan. Alliance utilizes a data management system to track engagement activities with stakeholders and records feedback resulting from 4000 surveys distributed and 750 face-face visits.

During the interviews with the LRCM staff advised that it currently measures the effectiveness of its Public Awareness program from its surveys results. At the time of the audit Alliance advised the Board that it was in year two of a four year evaluation of effectiveness; however the qualitative data resulting from the surveys would not be available for another two years and that currently it only had quantitative data available to measure effectiveness.

The 2015 quantitative return rate for the surveys was 2.5%. The Board is of the view that this quantitative measure is not a representative sample to determine the interim effectiveness of the Public Awareness program. Alliance did advise that although the qualitative data will not be evaluated until the end of the four years, it addresses identified issues on an individual basis.

While Alliance demonstrated the implementation of its processes, it did not demonstrate that it was currently evaluating practices such as feedback submitted. Based on the lack of consistent management of recommendations, the Board determined that Alliance did not demonstrate the effectiveness of its processes. In addition, Alliance did not demonstrate that program changes and continuous improvements following the annual assessment and suggested improvements are reviewed and evaluated for incorporation into the following year’s plan. For example, the 2012 Alliance Public Awareness program review indicated that the Public Awareness program activities “needed to be proactive rather than reactive”. When asked to discuss its follow-up on this feedback, Alliance did not provide its review to demonstrate that it was evaluated. In fact, Alliance later stated that there have been no documented or formal changes to the Public Awareness program materials being distributed or type and number of outreach activities conducted since 2012.

Monitoring and analyzing trends

The Board expects companies to have an established, maintained and effective data management system for monitoring and analyzing trends, incidents and near misses. The company shall also have documentation and records resulting from the inspection and monitoring activities for its programs. As well, the Board expects the management system will ensure coordination between its protection programs and the company shall integrate the results of its inspection and monitoring activities with other data in its hazard identification and analysis, risk assessments, performance measures and annual management reviews, to ensure continual improvement in meeting the company’s obligation for safety, security and protection of the environment.

Alliance was able to demonstrate that it has a data management system where it inputs information related to its Third Party Crossings program such as requests for permission and unauthorized activities. It also demonstrated that it maintains contacts and feedback from surveys within its LRCM database.

Alliance demonstrated that it is meeting its Board requirements for reporting unauthorized activities. However, as discussed in the review of sub-element 2.1 of this report, Alliance did not demonstrate it applied its analysis of trends, such as those identified through unauthorized activity reporting, to its Public Awareness program activities. Further, Alliance did not measure whether the deliverables and activities of the Public Awareness program had an impact on unauthorized activities. The Board expects companies to illustrate the types of unauthorized activities that are being reported in order to promote the identification of hazards and trends in unauthorized activities and design the Public Awareness program in response to those trends. The Board considers this type of analysis as a basic requirement for analyzing the effectiveness of program activities.

Summary

The Board found that Alliance’s staff at all levels of the Public Awareness program were aware of the methods to track and report on the program related activities and how that information is used to develop the Public Awareness program for the following year. Alliance was able to demonstrate that it uses several methods to monitor and measure their performance.

The Board found that Alliance has not established and implemented a process for inspecting and monitoring the company’s activities to evaluate the adequacy and effectiveness of the Public Awareness program as required by the Board.

Compliance Status: Non-Compliant

4.2 Investigating and Reporting Incidents and Near-misses

Expectations:

The company shall have an established, implemented and effective process for reporting on hazards, potential hazards, incidents and near-misses, and for taking corrective and preventive actions. This should include conducting investigations where required or where hazards, potential hazards, incidents and near-misses have or could have resulted in the safety and security of the public, company employees and the pipeline, and protection of property and the environment, being significantly compromised.

The company shall have an established, maintained and effective data management system for monitoring and analyzing the trends in hazards, incidents and near-misses.

The company should integrate the results of its reporting on hazards, potential hazards, incidents and near-misses with other data in hazard identification and analysis, risk assessments, performance measures and annual management reviews, to ensure continual improvement in meeting the company’s obligations for safety, security and protection of the environment.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(r),(s),(u),(w),(x), 40, 47, 48, 52

Assessment:

The Board requires that companies have an established process for reporting on hazards, potential hazards, incidents and near-misses that occur on its regulated facilities. The Board also expects companies to have an established, maintained and effective data management system for monitoring and analyzing the trends in hazards, incidents and near-misses.

Reporting on hazards, potential hazards, incidents and near-misses

The Board found that Alliance’s internal reporting process is managed through a software database system managed at the corporate level. Alliance demonstrated that, once notified, Alliance Public Awareness personnel conduct a follow-up investigation on each reported item including unauthorized activities, to determine if damage to the facilities or environment had occurred and to provide additional public awareness material. Through document and record reviews, the Board confirmed that Alliance had procedures in place for reporting and tracking any unauthorized activities.

Trending and Analysis

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

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

Alliance does apply some trending and analysis to its Public Awareness program development. Through its ROW patrol, Alliance identifies POIs further investigation and consideration with respect to possible stakeholder engagement activities. Also, Alliance demonstrated it has procedures in place to track near-misses by ensuring that unauthorized activities are captured in the corporate data management system, and followed-up for resolution. However, as previously indicated in this report, Alliance did not demonstrate that there were procedures to incorporate learnings from unauthorized activity follow-up investigations into the Public Awareness program.

Summary

The Board found that Alliance has a process to report unauthorized activities to the Board as required.

Based on the Board’s evaluation of Alliance’s Public Awareness program against the requirements, the Board has determined that Alliance is Compliant with this sub-element.

Compliance Status: Compliant

4.3 Internal Audits

Expectations:

The company shall have an established, implemented and effective quality assurance program for its management system and for each protection program, including a process for conducting regular inspections and audits and for taking corrective and preventive actions if deficiencies are identified. The audit process should identify and manage the training and competency requirements for staff carrying out the audits.

The company should integrate the results of its audits with other data in hazard identification and analysis, risk assessment, performance measures and annual management review, to ensure continual improvement in meeting the company’s obligations for safety, security and protection of the environment.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(w),(x) 40, 47, 48

Assessment:

The Board expects companies to have an established, implemented and effective quality assurance program for each protection program, including a process for conducting regular inspections and audits and for taking corrective and preventive actions if deficiencies are identified.

Quality Assurance Program

The specific requirements for establishing and implementing a quality assurance program are found within the OPR. While Alliance did demonstrate through its Annual Accountable Officer Report that it was undertaking quality assurance activities, Alliance did not demonstrate that it has a quality assurance program applicable to its Public Awareness program.

Alliance has established a review process for the Public Awareness program that includes annual internal reports. In addition, Alliance staff confirmed that they conduct annual surveys as part of a 4 year effectiveness evaluation to guage the level of understanding among its stakeholders. Information gathering for the assessment is in year 2 of 4, therefore no assessment will be conducted until 2017. It also uses the face-to-face visits and mail-in cards to obtain feedback from its external stakeholders.

Internal Audits

Although Alliance has not included its Public Awareness program within an internal audit program, it does conduct several types of reviews of the program’s performance. In order to assess the Public Awareness program, the Public Awareness coordinator conducts an annual review of the Tactical Plan. This program review includes the following aspects:

Newsletter frequency;
Target audience – is it still appropriate (audience is selected from API 1162);
Emergency Planning Zone;
Primary Baseline Messaging;
Saturation of messaging;
Supplemental messaging;
Emergency Response Liaison;
Evaluation of Effectiveness (4 yr survey); and
Continual improvement.

This review also contains a summary of the Public Awareness activities such as how many mail-outs were sent and meetings were conducted. It also assesses whether or not the program has met its targets and objectives. These results are then applied to the development of the following year’s plan.

In addition to the annual review of the tactical plan, Alliance also conducts periodic stakeholder surveys to guage the level of understanding among its stakeholders. It also uses the face-to-face visits and mail-in cards to obtain feedback from its external stakeholders. Interviews with Head Office staff confirm that Alliance conducts periodic assessments of effectiveness of its Public Awareness program consistent with the PCR requirements.

The Board found that the Public Awareness program had not been the subject of an internal audit. While Alliance provided information that demonstrated that it conducts reviews and assessments of public awareness initiatives, it did not demonstrate that it was evaluating this program in a manner consistent with its CSA Z662 requirements to conduct “periodic audits and reviews to evaluate the effectiveness of the safety and loss management system”.

Summary

The Board found that Alliance assesses its Public Awareness program for its effectiveness as required by the PCR, Part II section 4 (2).

The Board found that Alliance was undertaking many of the activities that are normally associated with a quality assurance program. The Board found, however, that Alliance had not organized them within a program as required by the OPR nor had it been audited to its legal requirements as per the Board’s requirements.

The Board also found that Alliance had not developed processes for conducting audits nor has completed an audit that meet the Board’s requirements.

Compliance Status: Non-Compliant

4.4 Records Management

Expectations:

The company shall have an established, implemented and effective process for generating, retaining, and maintaining records that document the implementation of the management system and its protection programs, and for providing access to those who require them in the course of their duties.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(p), 40, 47, 48

Assessment:

The Board requires companies to have an established, implemented and effective process for generating, retaining, and maintaining records that document the implementation of the management system and its protection programs, and for providing access to those who require them in the course of their duties.

To demonstrate its compliance, Alliance provided the following documents:

Record and Information Management Policy;
Document and Records Management Program;
Records Management Practice; and
Functional Records Classification and Retention Schedule.

The Board found that while the specific OPR process requirements to generate, retain and maintain records to document the implementation of the management system and the protection programs could be accounted for by reviewing these documents in their totality, the Board requires that a singular management system process be established and implemented to ensure ease of use and understanding amongst company employees. Further, Alliance has developed an internal document hierarchy, which includes when processes (among other type of documents) should be developed and how these documents are defined. The Board reviewed this definition and it determined that it does align with the Board expectations; however, it is not been used consistently in the organization.

Despite the process deficiency, the Board verified that Alliance has a number of established practices for records retention. Alliance has several databases for locate requests, third party requests for permissions, land tract profiles, unauthorized activities, right of way issues and crossing inspection reports. Alliance maintains a geographic information system to manage and document work conducted on the right of way and is accessible to field staff. This database can also be leveraged to manage stakeholder contact information for its Public Awareness and Emergency Management programs.

Summary

The Board found that Alliance had implemented consistent records management practices to document the implementation of its Public Awareness program.

The Board also found that Alliance has not established and implemented a Public Awareness program process that meets the OPR requirements.

Compliance Status: Non-Compliant

5.0 MANAGEMENT REVIEW

5.1 Management Review

Expectations:

The company shall have an established, implemented and effective process for conducting an annual management review of the management system and each protection program and for ensuring continual improvement in meeting the company’s obligations to perform its activities in a manner that ensures the safety and security of the public, company employees and the pipeline, and protection of property and the environment. The management review should include a review of any decisions, actions and commitments which relate to the improvement of the management system and protection programs, and the company’s overall performance.

The company shall complete an annual report for the previous calendar year, signed by the accountable officer, that describes the performance of the company’s management system in meeting its obligations for safety, security and protection of the environment and the company’s achievement of its goals, objectives and targets during that year, as measured by the performance measures developed under the management system and any actions taken during that year to correct deficiencies identified by the quality assurance program. The company shall submit to the Board a statement, signed by the accountable officer, no later than April 30 of each year, indicating that it has completed its annual report.

References:

PCR Part II section 4; OPR sections 6.1, 6.5(1)(w),(x), 6.6, 40, 47, 48

Assessment:

(Note – The sub-element is attributed to companies’ senior management and Accountable Officer; therefore, the Board does not break up its review into governance and program levels.)

Annual Management Review of Management System and Public Awareness Program Process

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

Accountable Officer Report Process;
Operational Excellence Management System – OEMS Management Review Process;
Land, Right of Way & Corridor Management (LRCM)Annual Program Review Practice

Upon review of the processes, practices and activities, as well as records supporting implementation of an annual management review, the Board noted the following:

Accountable Officer Report Process
- At the time of the audit, the process was not established as per the Board’s working definition, as the document was approved in June 2015. However, interviews confirmed it implemented by practice in order to prepare the 2014 Annual Accountable Officer Report;
- The design of the process meets Board’s working definition as it includes the 5 w’s and h approach (who, what, where, when, why and how);
- Process does account for a review of the management system and Public Awareness program;
- Process does not stipulate the type of protection program level information that is to be provided as part of the review;
- Process does not stipulate who is responsible for completing the review of the management system; and
- Process does not stipulate how the annual management reviews ensure continual improvement in meeting the company obligations to protect the safety and security of the people, the pipeline and for the protection of the environment.
OEMS Management Review Process
- The title refers to a process but the document itself refers to it as procedure;
- As this process/procedure has been in place since 2008, it does meet the Board’s definition of established and implemented;
- The design of the process meets Board’s working definition as it includes the 5 w’s and h approach (who, what, where, when, why and how);
- This review process/procedure is not integrated with the Accountable Officer Report Process referred to above;
- Records reviewed by the Board verified that a quarterly assertion is conducted by the department owners to ensure that program level processes as they pertain to core functions are adequate and that key measures are on track;
- Reviews are being completed at the process or department level, which does not ensure performance at the protection program level;
- Review of the management system is not part of this process; and
- Department level objectives and key measures within this review process do not align with the management system goals, objectives and targets established through Alliance’s practice as referred to in Sub-element 2.3 of this audit report.
Land, Right of Way & Corridor Management Annual Program Review Practice
- As prescribed, this practice is intended to be a conformance check to ensure that LRCM processes are being followed and revised as necessary;
- This activity is not integrated by process to either the Accountable Officer Report Process and OEMS Management Review Process referred to above; and
- This practice does not meet the Board’s definition of a process as it does not include the Board’s common 5 w’s and h approach (who, what, where, when, why and how). Further, Alliance has a developed an internal document hierarchy, which includes when processes (amongst other type of documents) should be developed and how it is defined. The Board reviewed this definition and it determined that it does align with the Board expectations; however, it is not been used consistently in the organization.

Management System Evaluation Process

While the Board has listed this requirement under sub-element 4.1 of the Protocol, Alliance indicated during the audit that its Accountable Officers Report Process is also used to evaluate the adequacy and effectiveness of the company’s management system. In reviewing the content of this process and as set out above the Board notes the following:

At the time of the audit, the process was not established as per the Board’s working definition as the document was approved in June 2015. However, interviews confirmed it was implemented by practice in order to prepare the 2014 Accountable Officer Report;
The design of the process meets Board’s working definition as it includes the 5 w’s and h approach (who, what, where, when, why and how); and
Process does not explicitly indicate how the adequacy and effectiveness of the company’s management system is evaluated and this would need to be inferred through several activities within the process.

Based on the Board’s evaluation of Alliance’s management system and Public Awareness program against the requirements, the Board has determined that Alliance has not established and implemented a process for evaluating the adequacy and effectiveness of its management system. Alliance will have to develop corrective actions to address the described deficiencies.

Annual Report

According to OPR section 6.6, Alliance must complete its annual Accountable Officer Report, have it signed by the accountable officer, and submit confirmation of completion to the Board no later than April 30 each year. The Board confirmed that the Accountable Officer Report for the 2014 performance year was signed by the accountable officer and confirmation of completion was submitted to the Board on April 17, 2015.

Alliance develops an annual Accountable Officer Report that summarizes the performance of its OEMS and supporting protection programs. Alliance divides the report into five main parts:

Overview of protection programs and management systems;
Performance management: management system goals and results;
Quality assurance;
Progress against the previous year’s improvement recommendations; and
Recommendations for the coming year.

Upon review of the annual Accountable Officer Report, the Board noted that the report does describe the performance of the company’s management system in meeting its obligations to ensure the safety and security of the people, the pipeline and the protection of the environment. In addition, the report also describes the company’ quality assurancs achievement of its established goals, objectives and targets. The annual Accountable Officer Report also includes a section that describes thee activities that occurred in that year. However, Alliance’s annual Accountable Officer Report does not specify the actions taken during that year to correct any deficiencies identified by the quality assurance program. Thus, it is unclear whether the accountable officer is aware of these actions and deficiencies.

Management Responsibility

Further to the review of these processes and activities, the Board notes that Alliance has not conducted audits consistent with its OPR and CSA obligations. The Board views the responsibility for undertaking these audits as resting with the company’s senior management (as represented by its accountable officer) as the annual report developed as per OPR specifically requires review and reporting on aspects of the Quality Assurance Program (specifically including audits) and the performance of the management system in meeting its obligations under OPR section 6.

Summary

The Board found that Alliance had developed processes for and undertaken activities relating to its Management Review responsibilities. The Board also found that Alliance’s processes did not meet all of the requirements outlined in the OPR.

The Board also found that some of the Non-Compliant findings in this audit are related to sub-elements where Alliance’s Senior Management has responsibilities to ensure that management direction, oversight and formal monitoring are occurring.

Compliance Status: Non-Compliant

Footnotes

Footnote i

The “References” in this table contain specific examples of the legal requirements applicable to each element but are not exhaustive and do not represent a complete list of all applicable legal requirements audited to, which are found within the NEB Act and its associated regulations, as well as other applicable legislation, technical and other standards including the Canada Labour Code and CSA Z662, and any conditions contained within applicable certificates or orders enforced by the Board.

Return to footnote i referrer

Footnote 1

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

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Date modified:: 2021-07-20

ARCHIVED - National Energy Board Onshore Pipeline Regulations (OPR) – Final Audit Report of the Alliance Pipeline Ltd. Public Awareness Program – Appendix I – Public Awareness Program Audit Evaluation Table

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Table of Contents

1.0 POLICY AND COMMITMENT

1.1 Leadership Accountability

Expectations:

References:

Assessment:

Accountable Officer

Summary

Compliance Status: Compliant

1.2 Policy and Commitment Statements

Expectations:

References:

Assessment:

Policies

Public Awareness Program Policy

Summary

Compliance Status: Non-Compliant

2.0 PLANNING

2.1 Hazard Identification, Risk Assessment and ControlFootnote 1

Expectations:

References:

Assessment:

Identifying, Analyzing and Evaluating Hazards

Hazard Inventory and Risk Assessment

Control

Summary

Compliance Status: Non-Compliant

2.2 Legal Requirements

Expectations:

References:

Assessment:

Identifying and Monitoring Compliance

Legal List

Communicating Legal Requirements

Summary

Compliance Status: Non-Compliant

2.3 Goals, Objectives and Targets

Expectations:

References:

Assessment:

Goals, Objectives and Targets

Summary

Compliance Status: Non-Compliant

2.4 Organizational Structure, Roles and Responsibilities

Expectations:

References:

Assessment:

Organizational Structure

Annual Evaluation of Resource Need

Summary

Compliance Status: Non-Compliant

3.0 IMPLEMENTATION

3.1 Operational Control-Normal Operations

Expectations:

References:

Assessment:

Development of Controls

Summary

Compliance Status: Non-Compliant

3.2 Operational Control-Upset or Abnormal Operating Conditions

Expectations:

References:

Assessment:

Upset or Abnormal Operating Conditions

Contingency Plans

Summary

Compliance Status: Non-Compliant

3.3 Management of Change

Expectations:

References:

Assessment:

Summary

Compliance Status: Non-Compliant

3.4 Training, Competence and Evaluation

Expectations:

References:

Assessment:

Developing Competency Requirements and Training Programs

2.1 Hazard Identification, Risk Assessment and Control^{Footnote 1}