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National Energy Board Onshore Pipeline Regulations (OPR) – Final Audit Report of the Enbridge Pipelines Inc. Emergency Management Program – OF-Surv-OpAud-E101-2014-2015 03 [PDF 988 KB]

File OF-Surv-OpAud-E101-2014-2015 03
31 March 2015

Mr. Guy Jarvis
President, Liquids Pipelines
Accountable Officer under the NEB Act
Enbridge Pipelines Inc.
3000 Fifth Avenue Place
425 - 1st Street S.W.
Calgary, AB T2P 3L8
Facsimile Information not available

Dear Mr. Jarvis:

Enbridge Pipelines Inc. (Enbridge) and its Board-Regulated Subsidiaries
- National Energy Board Onshore Pipeline Regulations, (OPR) Final Audit Report
- Emergency Management Program

The Board has completed its Final Report for its audit of Enbridge’s Emergency Management Program.

A Draft Report documenting the Board’s evaluation of Enbridge’s Emergency Management Program was provided to Enbridge on 4 February 2015 for review and comment. On 6 March 2015, Enbridge submitted its response.

The Board has considered Enbridge’s comments and has made changes to the Final Audit Report and its Appendices as it determined to be appropriate.

The findings of the audit are based upon an assessment of whether Enbridge was compliant with the regulatory requirements contained within:

National Energy Board Act;
National Energy Board Onshore Pipeline Regulations; and
Enbridge’s policies, programs, practices and procedures.

Enbridge was required to demonstrate the adequacy and effectiveness of the methods selected and employed within its Programs to meet the regulatory requirements listed above.

The Board has enclosed the Final Audit Report and associated appendices with this letter. The Board will make the Final Audit Report public on the Board’s website.

Within 30 days of the issuance of the Final Audit Report by the Board, Enbridge is required to file a Corrective Action Plan (CAP), which describes the methods and timing for addressing the Non-Compliant findings identified through this audit, for approval.

The Board will make the CAP public and will continue to monitor and assess all of Enbridge’s corrective actions with respect to this audit until they are fully implemented. The Board will also continue to monitor the implementation and effectiveness of Enbridge’s Emergency Management Program and management system through targeted compliance verification activities as a part of its on-going regulatory mandate.

If you require any further information or clarification, please contact Ken Colosimo, Lead Auditor, Operations Business Unit, toll-free at 1-800-899-1265.

Yours truly,

Original signed by

Sheri Young
Secretary of the Board

Attachment - Final OPR Audit Report documents

cc: Mr. Al Monaco, President and CEO, Enbridge Inc.

National Energy Board Onshore Pipeline Regulations (OPR)
Final Audit Report of the Enbridge Pipelines Inc. Emergency Management Program

File Number: OF-Surv-OpAud-E101-2014-2015 03

Enbridge Pipelines Inc. and National Energy Board-Regulated Subsidiaries (Enbridge)
3000 Fifth Avenue Place
425 -1st Street S.W.
Calgary, Alberta T2P 3L8

31 March 2015

Executive Summary

Companies regulated by the National Energy Board (NEB or the Board) must demonstrate a proactive commitment to continual improvement in safety, security and Emergency Management. Pipeline companies under the Board’s regulation are required to incorporate adequate, effective and implemented management systems into their day-to-day operations. These systems and associated technical management programs include the tools, technologies and actions needed to ensure NEB regulated pipelines are safe and remain that way over time. In the public interest, the Board holds companies accountable for safety and environmental outcomes.

This report documents the Board’s comprehensive audit of Enbridge’s management system and Emergency Management program applicable to its facilities that are regulated by the NEB. The audit was conducted using the National Energy Board Onshore Pipeline Regulations (OPR) as amended on 21 April 2013. This amendment clarified the Board’s expectations for establishing and implementing a documented management system and Emergency Management program. Before issuing the amendment, the Board consulted and communicated with its regulated companies with respect to the new requirements; therefore, an implementation grace period was not given when the OPR was promulgated. As a result, when evaluating compliance, this audit did not consider any extra time Enbridge may have needed to implement changes associated with the formalized management system requirements. As indicated in the amendments, companies must have an effective and well-documented Emergency Management program as a key component of their management system.

The Board conducted the audit following its published audit protocol, which identifies five management system elements. These five elements are broken into 17 sub-elements. Each sub-element reflects several regulatory requirements. Companies must comply with 100 per cent of the regulatory requirements of each sub-element being assessed. If a company’s program is found to be deficient with respect to any regulatory requirement, the entire sub-element will be found Non-Compliant. This report also includes an assessment of Enbridge’s management system against the requirements of OPR, section 6.1.

The Board’s audit of Enbridge’s regulated facilities found that Enbridge is in the process of establishing and implementing a management system that reflects its commitment to applying a formal management structure to all of its business functions and departments. Enbridge has not limited its management system to the technical programs required by the Board and was implementing a corporate management system, not merely an operations management system as many companies have done in response to the Board’s regulatory requirements.

The Board noted that Enbridge’s records indicate that it started developing its management system after the Board’s Integrity Management and Safety Management program audits in 2009. This was before Enbridge was notified of the intended OPR changes.

Regardless of when Enbridge started its management system development, its commitment to establishing and implementing a corporate management system for all of its Board regulated business and facilities is a large, complex undertaking. The Board therefore identified that Enbridge’s management system is in a transitory state between the program-based management practices it used in the past and its new management system approach. This has contributed to a Non-Compliant finding related to establishing and implementing a compliant management system. It is important to understand that the Board’s finding regarding Enbridge’s management system primarily reflects the company’s stage in developing and applying its management system. It does not necessarily reflect the lack of technical management activities being undertaken to ensure the safety of the pipeline.

The Board’s audit of Enbridge’s management system included an assessment of the individual management system processes as described in the OPR and the Board’s audit protocol. As documented in this report, the Board found that Enbridge has documented many of the required processes within its Integrated Management System. However, the Board found that some of Enbridge’s management system processes were not sufficiently systematic, explicit, comprehensive and proactive to meet the OPR requirements.

The Board notes that, regardless of the reasons for non-compliance, companies were required to be compliant with the Board’s management system requirements when the Onshore Pipeline Regulations were updated in 2013. Enbridge will need to develop and implement corrective actions to ensure establishment and implementation of its management system.

In addition to evaluating Enbridge’s management system and associated processes, the Board’s audit also included an evaluation of Enbridge’s Emergency Management program to determine the applicability and integration of the management system within it and to assess whether Enbridge is meeting its requirements to develop, implement and maintain an Emergency Management program that anticipates, prevents, manages and mitigates conditions that could adversely affect the environment during the operation and maintenance of its pipeline. The Board found that, notwithstanding the documentation issues relating to its management system processes, the processes and practices presently used by Enbridge identified the majority, and most significant, of its emergency management related hazards and that Enbridge has developed and implemented operational controls and inspection and monitoring programs to address these hazards. The Board notes that Enbridge’s Emergency Management program has been in existence for many years, thus its related practices and procedures are well established within the organization. The Board did identify some deficiencies not related to management system process development. All of the Board’s findings are documented in Appendix I of this audit report.

In analyzing the results of its audit as a whole, the Board notes that it has made a significant number of Non-Compliant findings. The majority of these findings fall into three general categories:

Non-compliances relating to management system process development;
Non-compliances relating to Enbridge’s interpretation of OPR requirements; and
Non-compliances relating to technical content.

The Board notes that the majority of all of the Non-Compliant findings made by the Board relate to management system process development.

The Board has determined that enforcement actions are not immediately required to address the Non-Compliant findings identified in this audit. Within 30 days of the Final Audit Report being issued, Enbridge must develop and submit a Corrective Action Plan for Board approval. The Corrective Action Plan must detail how Enbridge intends to resolve the non-compliances identified by this audit. The Board will assess implementation of the corrective actions to confirm they are completed in a timely manner and applied consistently across Enbridge’s regulated system. The Board will also continue to monitor the overall implementation and effectiveness of Enbridge’s management system and Emergency Management program through targeted compliance verification activities as part of its ongoing regulatory mandate.

1.0 Audit Terminology and Definitions

(The Board has applied the following definitions and explanations in measuring the various requirements included in this audit. They follow or incorporate legislated definitions or guidance and practices established by the Board, where available.)

Adequate: The management system, programs or processes complies with the scope, documentation requirements and, where applicable, the stated goals and outcomes of the NEB Act, its associated regulations and referenced standards. Within the Board’s regulatory requirements, this is demonstrated through documentation.

Audit: A systematic, documented verification process of objectively obtaining and evaluating evidence to determine whether specified activities, events, conditions management systems or information about these matters conform to audit criteria and legal requirements and communicating the results of the process to the company.

Compliant: A program element meets legal requirements. The company has demonstrated that it has developed and implemented programs, processes and procedures that meet legal requirements.

Corrective Action Plan: A plan that addresses the non-compliances identified in the audit report and explains the methods and actions that will be used to correct them.

Developed: A process or other requirement has been created in the format required and meets the described regulatory requirements.

Effective: A process or other requirement meets its stated goals, objectives, targets and regulated outcomes. Continual improvement is being demonstrated. Within the Board’s regulatory requirements, this is primarily demonstrated by records of inspection, measurement, monitoring, investigation, quality assurance, audit and management review processes as outlined in the OPR

Established: A process or other requirement has been developed in the format required. It has been approved and endorsed for use by the appropriate management authority and communicated throughout the organization. All staff and persons working on behalf of the company or others that may require knowledge of the requirement are aware of the process requirements and its application. Staff has been trained on how to use the process or other requirement. The company has demonstrated that the process or other requirement has been implemented on a permanent basis. As a measure of “permanent basis”, the Board requires the requirement to be implemented, meeting all of the prescribed requirements, for three months.

Finding: The evaluation or determination of the compliance of programs or elements in meeting the requirements of the National Energy Board Act and its associated regulations.

Implemented: A process or other requirement has been approved and endorsed for use by the appropriate management authority. It has been communicated throughout the organization. All staff and persons working on behalf of the company or others that may require knowledge of the requirement are aware of the process requirements and its application. Staff has been trained on how to use the process or other requirement. Staff and others working on behalf of the company have demonstrated use of the process or other requirement. Records and interviews have provided evidence of full implementation of the requirement, as prescribed (i. e. the process or procedures are not partially utilized).

Inventory: A documented compilation of required items. It must be kept in a manner that allows it to be integrated into the management system and management system processes without further definition or analysis.

List: A documented compilation of required items. It must be kept in a manner that allows it to be integrated into the management system and management system processes without further definition or analysis.

Maintained: A process or other requirement has been kept current in the format required and continues to meet regulatory requirements. With documents, the company must demonstrate that it meets the document management requirements in OPR, section 6.5 (1)(o). With records, the company must demonstrate that it meets the records management requirements in OPR, section 6.5 (1)(p).

Management System: The system set out in OPR sections 6.1 to 6.6. It is a systematic approach designed to effectively manage and reduce risk, and promote continual improvement. The system includes the organizational structures, resources, accountabilities, policies, processes and procedures required for the organization to meet its obligations related to safety, security and Emergency Management.

(The Board has applied the following interpretation of the OPR for evaluating compliance of management systems applicable to its regulated facilities.)

As noted above, the NEB management system requirements are set out in OPR sections 6.1 to 6.6. Therefore, in evaluating a company’s management system, the Board considers more than the specific requirements of section 6.1. It considers how well the company has developed, incorporated and implemented the policies and goals on which it must base its management system as described in section 6.3; its organizational structure as described in section 6. 4; and considers the establishment, implementation, development and/or maintenance of the processes, inventory and list described in section 6.5(1). As stated in sections 6.1(c) and (d), the company’s management system and processes must apply and be applied to the programs described in section 55.

Non-Compliant: A program element does not meet legal requirements. The company has not demonstrated that it has developed and implemented programs, processes and procedures that meet the legal requirements. A corrective action plan must be developed and implemented.

Practice: A repeated or customary action that is well understood by the persons authorized to carry it out.

Procedure: A documented series of steps followed in a regular and defined order thereby allowing individual activities to be completed in an effective and safe manner. A procedure also outlines the roles, responsibilities and authorities required for completing each step.

Process: A documented series of actions that take place in an established order and are directed toward a specific result. A process also outlines the roles, responsibilities and authorities involved in the actions. A process may contain a set of procedures, if required.

(The Board has applied the following interpretation of the OPR for evaluating compliance of management system processes applicable to its regulated facilities.)

OPR section 6.5(1) describes the Board’s required management system processes. In evaluating a company’s management system processes, the Board considers whether each process or requirement: has been established, implemented, developed or maintained as described within each section; whether the process is documented; and whether the process is designed to address the requirements of the process, for example a process for identifying and analyzing all hazards and potential hazards. Processes must contain explicit required actions including roles, responsibilities and authorities for staff establishing, managing and implementing the processes. The Board considers this to constitute a common 5 w’s and h approach (who, what, where, when, why and how). The Board recognizes that the OPR processes have multiple requirements; companies may therefore establish and implement multiple processes, as long as they are designed to meet the legal requirements and integrate any processes linkages contemplated by the OPR section. Processes must incorporate or contain linkage to procedures, where required to meet the process requirements.

As the processes constitute part of the management system, the required processes must be developed in a manner that allows them to function as part of the system. The required management system is described in OPR section 6.1. The processes must be designed in a manner that contributes to the company following its policies and goals established and required by section 6.3.

Further, OPR section 6.5(1) indicates that each process must be part of the management system and the programs referred to in OPR section 55. Therefore, to be compliant, the process must also be designed in a manner which considers the specific technical requirements associated with each program and is applied to and meets the process requirements within each program. The Board recognizes that single process may not meet all of the programs; in these cases it is acceptable to establish governance processes as long as they meet the process requirements (as described above) and direct the program processes to be established and implemented in a consistent manner that allows for the management system to function as described in 6.1.

Program: A documented set of processes and procedures designed to regularly accomplish a result. A program outlines how plans, processes and procedures are linked; in other words, how each one contributes to the result. A company regularly plans and evaluates its program to check that the program is achieving the intended results.

(The Board has applied the following interpretation of the OPR for evaluating compliance of programs required by the NEB regulations.)

The program must include details on the activities to be completed including what, by whom, when, and how. The program must also include the resources required to complete the activities.

2.0 Abbreviations

CAP: Corrective Action Plan

CLC: Canada Labour Code Part II

CSA Z662-11: CSA Standard Z662 entitled Oil and Gas Pipeline Systems, 2011 version

COHSR: Canada Occupational Health and Safety Regulations

Enbridge: Enbridge Pipelines Inc. and its NEB-regulated subsidiaries

EMP: Emergency Management program

GOT: Goals, Objectives and Targets

IMS: Enbridge’s Integrated Management System

NEB: National Energy Board

OPR: National Energy Board Onshore Pipeline Regulations

3.0 Introduction: NEB Purpose and Framework

The NEB’s purpose is to promote safety and security, environmental protection and efficient energy infrastructure and markets in the Canadian public interest within the mandate set by Parliament in the regulation of pipelines, energy development and trade. In order to assure that pipelines are designed, constructed, operated and abandoned in a manner that ensures: the safety and security of the public and the company’s employees; safety of the pipeline and property; and protection of the environment, the Board has developed regulations requiring companies to establish and implement documented management systems applicable to specified technical management and protection programs. These management systems and programs must take into consideration all applicable requirements of the NEB Act and its associated regulations. The Board’s management system requirements are described within OPR, sections 6.1 through 6.6.

To evaluate compliance with its regulations, the Board audits the management system and programs of regulated companies. The Board requires each regulated company to demonstrate that they have established and implemented, adequate and effective methods for proactively identifying and managing hazards and risks.

As part of the audit, the Board reviews the compliance and incident history of the company as recorded in NEB files. This helps the Board determine the appropriate scope for the audit. During the audit, the Board reviews documentation and samples records provided by the company in its demonstration of compliance and interviews corporate and regionally-based staff.

The Board also conducts separate but linked technical inspections of a representative sample of company facilities. This enables the Board to evaluate the adequacy, effectiveness and implementation of the management system and programs. The Board bases the scope and location of the inspections on the needs of the audit. The inspections follow the Board’s standard inspection processes and practices. Although they inform the audit, inspections are considered independent of the audit. If unsafe or non-compliant activities are identified during an inspection, they are actioned as set out by the Board’s standard inspection and enforcement practices.

After completing its field activities, the Board develops and issues a Final Audit Report. The Final Audit Report outlines the Board’s audit activities, provides evaluations of the company’s management system and programs, identifies deficiencies and communicates compliance findings. The audit report follows the format of the Board’s published Audit Protocol. Once the Board issues the Final Audit Report, the company must submit and implement a Corrective Action Plan to address all Non-Compliant findings. Final Audit Reports are published on the Board’s website. The audit results are integrated into NEB’s risk-informed lifecycle approach to compliance assurance.

4.0 Background

Enbridge operates approximately 10,733 km of pipeline in six Canadian provinces and territories. These pipeline facilities include pump stations, tankage and associated operational assets. All of these facilities are within the definition of a “pipeline” as included in the NEB Act. Enbridge also has a considerable amount of non-federally regulated infrastructure in Alberta and across the United States, which complete its North American system. Enbridge’s system allows it to transport liquids from northern and western Canada to end-users in the Eastern regions of Canada and the United States. In order for Enbridge to operate its pipelines effectively, it has developed a management structure that reflects its safety and security management, and environmental obligations, as well as its corporate, national, regional and international needs. Enbridge Pipelines Inc. controls and uses several entities that hold NEB-issued certificates for operating in Canada. The entities included within the scope of this audit are identified in Section 5.0, Audit Objectives and Scope of this report.

During audit planning, company staff indicated that Enbridge and its subsidiaries operate the pipelines and facilities using a common management system and technical programs. In order to effectively evaluate compliance of such an expansive system within a reasonable timeframe, the Board chose to conduct individual, comprehensive audits of Enbridge’s required technical programs and management system. This report documents one of six management system and program audits. The audits are titled:

Enbridge Integrity Management Program Audit;
Enbridge Safety Management Program Audit;
Enbridge Environmental Protection Program Audit;
Enbridge Emergency Management Program Audit;
Enbridge Third-Party Crossings Program Audit; and
Enbridge Public Awareness Program Audit.

Audit results confirmed that Enbridge operates its facilities using a common organizational structure to implement a common governance management system that applies to all of its business and operational activities. Some findings are therefore similar in each audit and the individual audit reports reflect this.

5.0 Audit Objectives and Scope

The objective of the audit was to determine the establishment and implementation of Enbridge’s management system and the adequacy and effectiveness of its Emergency Management program. Enbridge was audited against the requirements contained within the following:

National Energy Board Act;
National Energy Board Onshore Pipeline Regulations; and
Enbridge’s policies, programs, practices and procedures.

This audit was conducted using the National Energy Board Onshore Pipeline Regulations (OPR) as amended on 21 April 2013. This amendment clarified the Board’s expectations for establishing and implementing a documented management system and Emergency Management program. Before issuing the amendment, the Board consulted and communicated with its regulated companies with respect to the new requirements; therefore, an implementation grace period was not given when the OPR was promulgated. As a result, when evaluating compliance, this audit did not consider any extra time Enbridge may have needed to implement changes.

As noted, Enbridge Pipelines Inc. companies hold a number of certificates to operate in Canada. The Board has included the following companies within the scope of this audit:

Enbridge Pipeline Inc.;
Enbridge Pipelines (NW) Inc.;
Enbridge Pipelines (Westspur) Inc.;
Enbridge Southern Lights GP Inc. on behalf of Enbridge Southern Lights LP; and
Enbridge Bakken Pipeline Company Inc. on behalf of Enbridge Bakken Pipeline Limited Partnership.

For more Enbridge facility information, refer to Appendix II of this report.

6.0 Audit Process and Methodology

In undertaking this audit, the Board has applied its standard audit practice following its published protocols. The Board’s standard practice and audit activities include:

Formal notification of the Board’s intent to audit by letter;
Interactive planning processes with the company;
Information gathering;
Documentation and record review;
Program presentations by company personnel and interviews with company personnel;
Associated inspections and facility reviews;
Close-out discussions and meetings;
Developing and Issuing Draft Audit Report to Enbridge
Developing, finalizing and issuing the Final Audit Report;
Reviewing and approving any required Corrective Action Plans;
Reviewing implementation of Corrective Action Plans; and
Issuing closure letters.

These audit activities allow the company to demonstrate whether its management system and programs comply. They also allow the Board to evaluate the company with respect to: assuring compliance to regulatory requirements; and assuring appropriate safety, security and environmental outcomes as described in OPR, section 6.

As noted, Enbridge Pipelines Inc. operates an expansive liquids pipeline system using a common management system and Emergency Management program. Furthermore, Enbridge divides its Canadian assets into five operational regions: Northern Region, Western Region, Central Region, Southern Prairie Region and Eastern Region. The Board therefore developed its audit plan to evaluate Enbridge’s management system and Emergency Management program and to assure that it was appropriate to manage and applied to all of its regulated facilities regardless of location. To this end, the Board conducted interviews, inspections and documentation and record reviews in each region as well as the Edmonton office. It is the Board’s expectation that any audit Non-Compliant findings made and corrective actions required by the Board must be applied across all of Enbridge’s Board regulated systems and subsidiaries.

7.0 Audit Activities

The Board informed Enbridge Pipelines Inc. of its intent to audit its NEB regulated facilities in a letter dated 19 December 2013. Following the issuance of that letter, Board audit staff met with Enbridge staff on a regular basis to arrange and coordinate this audit. The Board also provided Enbridge with an information guidance document to help Enbridge prepare for the audit, and provide access to documentation and records to demonstrate its compliance. Enbridge established a digital access portal for Board staff to review documentation and records.

On 5 May 2014, an opening meeting was conducted with representatives from Enbridge in Edmonton, Alberta to confirm the Board’s audit objectives, scope and process. The opening meeting was followed by Edmonton office interviews from 5 to 16 May 2014, and various field level audit activities as described in the table below. Throughout the audit, Board audit staff gave Enbridge daily summaries with action items, where required.

On 21 and 22 October 2014, the Board held an audit pre-close-out meeting with Enbridge. At this meeting Board staff and Enbridge staff discussed potential deficiencies identified during field activities and discussed additional information that could be of value to the Board prior to compiling its draft audit report. An audit close-out meeting was held on 17 December 2014 to provide Enbridge with a description of the recommendations that staff would be bringing to the Board for decision.

Emergency Management Program Audit Office and Field Activities

Audit opening meeting (Edmonton, AB) - 5 May 2014
Edmonton office interviews (Edmonton, AB) - 5-16 May 2014
Field verification activities:
- Interviews - Sherwood Park, AB - 26-28 May 2014
- Interviews - Estevan, SK - 9-11 June 2014
- Interviews - Regina, SK - 12 June 2014
- Interviews - Sarnia, ON - 14 July 2014
- Exercise - Estevan, SK - 25 September 2014
Edmonton office interviews (Edmonton, AB) - 14-17 October 2014
Audit pre-close-out meeting of information gaps (Edmonton, AB) - 21-22 October 2014
Audit close-out meeting (Edmonton, AB) - 17 December 2014

8.0 Management System Evaluation

OPR, section 6.1 outlines the Board’s management system requirements as follows:

A company shall establish, implement and maintain a management system that

(a) is systematic, explicit, comprehensive and proactive;
(b) integrates the company’s operational activities and technical systems with its management of human and financial resources to enable the company to meet its obligations under section 6;
(c) applies to all the company’s activities involving the design, construction, operation or abandonment of a pipeline and to the programs referred to in section 55;
(d) ensures coordination between the programs referred to in section 55; and
(e) corresponds to the size of the company, to the scope, nature and complexity of its activities and to the hazards and risks associated with those activities.

In assessing Enbridge’s management system the Board applied the definitions and guidance as described in Section 1.0 Audit Terminology and Definitions of this report. The Board’s audit results indicated that Enbridge was in the process of establishing and implementing a management system that reflects its commitment to applying a formal management structure to all of its regulated business operations. Enbridge has not limited its management system to the technical programs required by the Board. The company appeared to be committed to implementing a corporate management system and not merely an operations management system as many companies do.

Enbridge’s records appeared to indicate that it started developing its management system after the Board’s Integrity and Safety Management program audits in 2009 and prior to the Board’s identification of its intended OPR changes.

Regardless of when Enbridge started its management system development, establishing a corporate management system applicable to all of its business and facilities is a large, complex undertaking. The Board’s audit therefore identified that Enbridge’s management system was in a transitory state between the program-based management practices it used in the past and its new management system approach.

In determining Enbridge’s compliance with respect to establishing and implementing a management system, the Board reviewed the audit results of Enbridge’s Emergency Management program processes along with the audit results of other Board program audits completed concurrently. This aided the Board in evaluating Enbridge’s systematic practices and deficiencies.

The Board found that Enbridge has not met the requirements for establishing and implementing a management system. For the most part, this reflected the transitory nature of its management system as applied to the Emergency Management program. The issues related to designing and establishing processes as described below and in Appendix 1 also contributed to the Board’s Non-Compliant finding. This is especially true with respect to Enbridge’s Quality Assurance Program and auditing process design.

The Board notes that it is important to understand that the Board’s management system Non-Compliant finding reflects the company’s deficiencies in developing and applying its management system. It does not necessarily reflect the lack of technical management activities being undertaken to ensure the protection of the environment.

The Board notes that, regardless of the reasons for non-compliance, companies were required to be compliant with the Board’s management system requirements when the OPR were updated in 2013. Enbridge will need to develop and implement corrective actions to ensure establishment and implementation of its management system.

The Board has further detailed its evaluation below in order for Enbridge to understand the nature of the Board’s management system finding to aid in development of its Corrective Action Plan.

The Board has found Enbridge Non-Compliant with OPR, section 6.1 (a).

This section requires management systems to be systematic, explicit, comprehensive and proactive. Enbridge’s documentation that describes its governance management system requirements clearly stated that the company’s management system is intended to meet these outcomes. The Board determined that Enbridge’s management system did meet the requirements for being systematic, explicit, comprehensive and proactive at an over-arching, system design level. However, as described below, the design of its processes, interpretation of some of the OPR requirements, lack of clarity with respect to some of the specific requirements, such as OPR section 6.3(a) and (b) policies and goals and its definition of risks vs hazards, did not meet the OPR requirements. This resulted in the Board determining that the present management system processes will not ensure that the company’s management system is systematic, explicit, comprehensive and proactive throughout all levels of the organization.

The Board found that Enbridge’s governance processes for their management system accounted for most of the Board’s process requirements by description. However, as described in Appendix I, there were issues associated with many of Enbridge’s processes. Enbridge has not designed all of its processes in a way that ensures the OPR process requirements are consistently met at the management system and program level. For example, the Board found that many of the processes did not include clear links to or include tier 2 and 3 procedures where inclusion would ensure appropriate or consistent implementation of the processes at the program level. This has led to some of the company’s processes being comprised of commitment statements rather than activity descriptions. Additionally, many of the company’s documented processes lacked full descriptions of the input and output processes and the products associated with each process. The Board found that Enbridge generally mitigated these process design deficiencies from an emergency management perspective; however, this was accomplished by program-level management practices and procedures. As well, Board documentation and record reviews and interviews with staff responsible for developing processes or programs indicated that many of the missing process components were actually being done by practice but have not been documented in Enbridge’s management system processes.

As part of Enbridge’s Corrective Action Plan to address its management system Non-Compliant finding, the Board is of the view that, Enbridge must develop and implement a compliant document control processes that meet OPR requirements for all new and existing documents in the company’s management system. This will serve to assure that the management system processes are designed appropriately and that existing or referenced documents fully meet the OPR requirements.

In reviewing Non-Compliant findings across the programs being audited concurrently by the Board, it is noted that several of the Non-Compliant findings related to Enbridge’s interpretation of OPR requirements. Enbridge provided specific information with respect to these interpretations during the audit. The Board noted that all regulations are subject to interpretation. However, many of Enbridge’s interpretations in this category did not reflect the wording of the regulations or standard management system practices. Examples of Enbridge’s interpretation issues can be found in the Board’s evaluation of the company’s quality assurance program, auditing, hazard identification and management of change processes, all of which are outlined in Appendix I of this document.

During its audit, the Board noted that Enbridge colour coded some process steps red in its governance process diagrams. According to the legend provided, red indicated that the process step should be considered aspirational. When interviewed, Enbridge staff indicated that aspirational refers to steps considered above regulatory requirements. The Board has given Enbridge and its regulated industry consistent information with respect to aspirational management practices. If a company identifies a practice as “above regulatory requirements, aspirational or stretch”, the Board will not hold that company accountable for implementing the practice as per OPR, section 4. This is to allow and encourage companies to include aspirational goals or practices in their overall management practices without fear of non-compliance when aspirational goals are not met. The Board found that some of the process steps Enbridge identified as aspirational were actually legally required. Examples of this included steps for identifying and verifying competencies in Enbridge’s IMS 01, 4.14 Workforce Competency and Qualification Process.

All of the comments above contribute to the Board’s Non-Compliant finding with respect to OPR section 6.1(a).

Based on the information from Enbridge and interviews with its staff, the Board’s audit did not identify any non-compliant issues related to OPR, sections 6.1(b) through (e).

Based on the Board’s evaluation of Enbridge’s management system against the OPR requirements, the Board has determined that Enbridge is Non-Compliant with section 6.1. Enbridge will have to develop a Corrective Action Plan to address the described deficiencies.

9.0 Program Summary

NEB-regulated companies must demonstrate a proactive commitment to continual improvement in safety, security, and environmental protection. Pipeline companies under the Board’s regulation are required to incorporate Emergency Management programs into their day-to-day operations. These programs must ensure that pipelines are operated in a manner that protects the environment.

During the audit Enbridge indicated that the Board’s required emergency management program requirements correspond to the company’s Emergency and Security Management System. The Board identified that Enbridge’s Emergency and Security Management System (IMS-07) is one of 19 management systems included in Enbridge’s Integrated Management System (IMS). Further review of Enbridge’s IMS indicated that it is actually comprised of 17 subordinate management systems, governed by two governance management systems, IMS - 01, Governing Policies and Processes Management System and IMS - 02, Compliance and Ethics Management System. These governance management systems outline minimum corporate requirements to be incorporated into each sub-ordinate management system of which IMS-07b is one. As noted previously in section 8.0 of this report, at the time of the audit the Board found that Enbridge had not established and implemented its required management system.

The Board has identified that primary responsibility for Enbridge’s Emergency Management program resides within its Emergency and Security department. This department is comprised of subject matter experts who are responsible for providing emergency and security leadership, promotion and direction in organizational activities through management system development and maintenance, stewardship, technical knowledge and support for Enbridge employees and contractors.

The Board identified that responsibility for implementation of the Emergency Management program resides with a number Enbridge’s functional departments. The Board therefore considered the sum of the Emergency and Security department and all other departments’ emergency management related responsibilities as comprising the Emergency Management program for the purposes of this audit.

Due to the transitory nature of Enbridge’s corporate management system, the Board found that Enbridge’s Emergency Management program framework was comprised of a mix of IMS processes and historically established and implemented processes and practices. It was noted during the audit that this transition has created gaps in continuity and consistency.

The Board found that the processes presently used by Enbridge identified the majority, and most significant, of its hazards and that Enbridge has developed and implemented the operational controls and inspection and monitoring programs to address these hazards. The Board also found that Enbridge’s Emergency Management program has been in existence for many years, thus the emergency related practices and procedures are well established within the organization. Notwithstanding these practices and procedures, the audit identified several non-compliant findings. The majority of the findings fall into three general categories:

Non-compliances relating to management system process development;
Non-compliances relating to Enbridge’s interpretation of OPR requirements; and
Non-compliances relating to technical content.

The Board has determined that no enforcement actions are immediately required to address the Non-Compliant findings identified in this audit. Within 30 days of the Final Audit Report being issued, Enbridge must develop and submit a Corrective Action Plan for Board approval detailing how it intends to resolve Non-Compliances identified by this audit. The Board will assess the implementation of the corrective actions to confirm that they are completed in an expedient manner, and on a system-wide basis. The Board will also continue to monitor the overall implementation and effectiveness of Enbridge’s management system and Emergency Management program through targeted compliance verification activities as a part of its on-going regulatory mandate.

10.0 Summary of Audit Findings

The Board conducted the audit following its published Audit Protocol, which identifies five Management System elements. These five elements are broken into 17 sub-elements. Each sub-element reflects several regulatory requirements. Companies must comply with 100 per cent of the regulatory requirements of each sub-element being assessed. If a company’s program is deficient in any regulatory requirement, the entire sub-element will be found non-compliant. The company will have to develop a corrective action plan to demonstrate to the Board that appropriate actions will be taken to achieve full compliance.

The following summary is a high-level overview of the Board’s audit findings for Enbridge’s Emergency Management program based on information provided by Enbridge during the audit.

Details of how each of the audited elements impacts the Emergency Management program and a full description of the Board’s assessment for each of its Management System sub-elements can be found in Appendix I of this report.

Element 1.0 - Policy and Commitment

Sub-element 1.1 - Leadership and Accountability

This sub-element of the audit requirements states that the company must appoint an Accountable Officer and notify the Board of the appointment.

Enbridge had submitted a written notice to the NEB indicating that it had appointed an Accountable Officer. In its submission, Enbridge confirmed that its Accountable Officer had authority over the human and financial resources required to meet the Board’s substantive expectations.

Based on the information provided by Enbridge, the Board has not identified any non-compliance issues. The Board has therefore assessed this sub-element as Compliant.

Sub-element 1.2 - Policy and Commitment Statements

This sub-element of the audit requirements states that the company must have documented policies and goals to ensure the safety and security of the public, workers, and the pipeline and ensure protection of property and the environment. Further, as these policies and goals are to be used to establish and implement the management and programs, the Board requires that the policies and goals be explicit from the perspective of design, content and communication.

The Board found that Enbridge had corporate and program level policies and goals that related to the Emergency Management program.

Notwithstanding the many policies, processes, principles, programs and initiatives that Enbridge had developed to direct and support its Emergency Management program, the Board identified non-compliance in the Policy and Commitment Statements sub-element.

Enbridge did not demonstrate that it had a policy that explicitly describes internal reporting of hazards, potential hazards, incidents and near misses and describes the conditions under which a person making a report will be granted immunity from disciplinary action.

Based on the Board’s evaluation of Enbridge’s management system and the Emergency Management program against the requirements, the Board has determined that Enbridge is Non-Compliant with this sub-element. Enbridge will have to develop corrective actions to address the described deficiencies.

Element 2.0 - Planning

Sub-element 2.1 - Hazard Identification, Risk Assessment and Control

This sub-element of the audit requirements states that the company must have an established, implemented and effective process for identifying and analyzing all hazards and potential hazards, assessing the degree of risk associated with the hazards, and implementing control measures to minimize or eliminate risk.

The Board found that Enbridge had developed a governance management system process for identifying, evaluating and managing its hazards and risks; however, the Board also found that this governance level management system process did not meet the OPR requirements.

The Board found that, at the program level, Enbridge’s hazard identification practices were considered to be simplistic and did not reflect common hazard identification practices. Enbridge’s identification of a singular hazard approach combined with its corporately focused and undemonstrated risk evaluation practices is considered to be a foundational issue with respect to developing a management system driven emergency management program. The Board has found that Enbridge has not developed the OPR required sequential stepped-approach of hazard and potential hazard identification, evaluation of risk and determination of controls.

The Board found that Enbridge had not developed a program level risk evaluation process that addressed the OPR requirements. During the audit Enbridge provided two documented processes as its Emergency Management program level risk evaluation processes. The Board found that the processes, alone or together, did not meet the OPR requirements as one focused on corporate risk and the other was applicable only to specific activities.

The Board found that Enbridge had not established and implemented a documented management system process to develop and implement controls to prevent, manage and mitigate its identified hazards and risks as part of its Emergency Management program.

Regardless of the lack of a compliant process for developing controls, the Board found that Enbridge had established and implemented emergency management related controls and control practices such as the development of emergency response plans, tactical plans, pre-identification of control points and acquisition and placement of emergency response. The Board found that the controls had been developed based on standard industry practices, input from its and other emergency response personnel and knowledge gathered during its exercise activities and past responses.

Based on the Board’s evaluation of Enbridge’s management system and Emergency Management program against the requirements, the Board has determined that Enbridge is Non-Compliant with this sub-element. Enbridge will have to develop corrective actions to address the described deficiencies.

Sub-element 2.2 - Legal Requirements

This sub-element of the audit requirements states that the company must have an established, implemented and effective process for identifying and monitoring compliance with all legal requirements applicable to the company. The company must also maintain a list of the legal requirements that apply to it.

The Board found that Enbridge had developed management system and program level processes for identifying and monitoring its legal requirements. The management system level process included requirements for development of compliance registers at both levels. The Board found that Enbridge’s management system level processes and compliance registers did not meet the OPR requirements with respect to design and content.

Sub-element 2.3 - Goals, Objectives and Targets

This sub-element of the audit requirements states that the company must have an established, implemented and effective process for developing and setting goals, objectives and specific targets for the risks and hazards associated with the company’s facilities and activities.

The Board found that, at both the management system and program levels, Enbridge had established and implemented a process that meets the Board’s requirements for establishing goals, objectives, targets and performance measures.

The Board also found that, although Enbridge had established and implemented a process for developing and setting, goals, objectives and targets, Enbridge did not demonstrate that it had established explicit goals related to its OPR section 6 obligations for it to base its management system and Emergency Management program on and as required by OPR, section 6.3.

Based on the Board’s evaluation of Enbridge’s management System and Emergency Management program against the requirements, the Board has determined that Enbridge is Non-Compliant with this sub-element. Enbridge will have to develop corrective actions to address the described deficiencies.

Sub-element 2.4 - Organizational Structure, Roles and Responsibilities

This sub-element of the audit requirements states that the company must have a documented organizational structure that enables it to meet the requirements of its management system. The company must also complete an annual documented evaluation to demonstrate that there is adequate human resourcing to meet these obligations.

The Board found that Enbridge had a documented organizational structure and communicates the roles responsibilities and authorities of the officers and employees at all levels of the company. Additionally, the Board found that Enbridge had adopted ICS that establishes a proven incident response organizational structure with documented roles and responsibilities.

The Board found that Enbridge had established and implemented several mechanisms for reviewing its emergency management program human resourcing needs. The Board, however, found deficiencies with Enbridge’s developed evaluation of need practices. Specifically, the Board also found that Enbridge’s evaluation of need practices did not specifically account for staff with emergency management responsibilities outside of the Emergency and Security department. Further, Enbridge did not demonstrate that it had documented an evaluation of the human resource needs required during an actual response.

Element 3.0 - Implementation

Sub-element 3.1 - Operational Control-Normal Operations

The Board notes that the Emergency Management program addresses only abnormal or upset operations. This section is therefore considered not to apply in this audit. The review of Enbridge’s controls is documented in sub-element 3.2, below.

Sub-element 3.2 - Operational Control-Upset or Abnormal Operating Conditions

This sub-element of the audit requirements states 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.

Based on interviews, and document and record reviews, the Board found that Enbridge demonstrated that it had numerous controls for its emergency program such as emergency response plans, tactical plans, tank fire plans etc. The Board found that Enbridge had developed its controls (plans, equipment etc.) based on industry practices, input from emergency response personnel expertise and experience with historical events. Further, the Board found that Enbridge has demonstrated that it had dedicated significant resources to acquiring equipment for emergency response and had also established agreements with response specialists and other industry organizations for emergency response preparedness and response activities.

The Board found that Enbridge developed controls that, based on the Board’s assessment, correspond to its hazards, risks, activities and locations.

The Board reviewed Enbridge’s Emergency Procedures manuals, as submitted to the Board, and has found deficiencies that Enbridge has agreed to rectify by 31 January 2015.

The Board has found that Enbridge has not utilized a sequential stepped approach for hazard and potential hazard identification, evaluation of risk and determination of controls. The Board further found that, in the absence of a compliant controls development and associated hazard and risk identification and evaluation processes, Enbridge could not formally demonstrate or verify that its existing controls were adequate or, in the case of equipment and associated human resources, located in appropriate locations.

The Board found that Enbridge had established and implemented ICS (Incident Command Structure) as its standard process for coordinating, controlling and managing the response activities of employees and other people working with or on behalf of the company during an incident.

Sub-element 3.3 - Management of Change

This sub-element of the audit requirements states that the company must have an established, implemented and effective process for identifying and managing any change that could affect safety, security or protection of the environment.

The Board found that Enbridge was in the process of establishing an updated management system management of change process. The Board found that this process did not meet the OPR requirements with respect to design, content.

The Board found that, at the program level, Enbridge had implemented a number of practices for management of change applicable to its Emergency Management program. The Board found that these practices did not meet all of the OPR requirements with respect to applicability and design.

Sub-element 3.4 - Training, Competence and Evaluation

This sub-element of the audit requirements states that the company must have an established, implemented and effective process for developing competency requirements and training programs for its employees and contractors. These competency requirements and training programs must enable employees and contractors to perform their duties in a manner that is safe, ensures the security of the pipeline, and protects the environment.

The Board found that Enbridge had established and implemented a training program for its employees and contractors. The Board also found that, while Enbridge had implemented some practices for reviewing the competencies of its workers, it had not established and implemented processes consistent with the requirements of OPR.

The Board notes that it brought this deficiency to Enbridge’s attention early in its audit process as a matter requiring urgent attention. Enbridge responded by developing a documented process that it provided to the Board’s auditors prior to the close-out of the field activities. Due to the early stage of development and implementation, Enbridge could not demonstrate the adequacy, effectiveness, establishment and implementation of the new process.

Sub-element 3.5 - Communication

This sub-element of the audit requirements states that the company must have an established, implemented and effective process for internally and externally communicating safety, security and Emergency Management information.

The Board found that Enbridge communicated internally and externally with respect to its emergency management program throughout its organization as a matter of practice.

The Board found that Enbridge had established a number of formal practices and methodologies to communicate and manage its communication during an emergency.

The Board also found that Enbridge had not established or implemented a communication process that meets the Board’s management system process requirements. Additionally, the Board found deficiencies relating to Enbridge’s Continuing Education and Liaison requirements.

Sub-element 3.6 - Documentation and Document Control

This sub-element of the audit requirements states that the company must have an established, implemented and effective process for identifying and managing the documents required to meet the company’s obligations for conducting activities in a manner that ensures the safety and security of the public, company employees and the pipeline, and that protects property and the environment.

The Board found that, at the program level, Enbridge demonstrated that it had developed document control lists and procedures and practices for managing and controlling its Emergency Management program documents that address many of the OPR requirements.

The Board also found that, at the governance level, Enbridge had developed its new IMS-01, section 4.9 Governance Document Control Process, dated 22 August 2014. However, Enbridge did not demonstrate that this process met the OPR requirements or had been established and implemented.

The Board also found that Enbridge did not demonstrate that it had implemented a process for identifying the documents required for the company to meet its obligations under section 6 and as required by OPR, section 6.5(1)(n).

Element 4.0 - Checking and Corrective Action

Sub-element 4.1 - Inspection, Measurement and Monitoring

This sub-element of the audit requirements states that the company must establish and implement an effective process for inspecting and monitoring its activities and facilities. This is so that the company can evaluate the adequacy and effectiveness of the protection programs and take corrective and preventive actions if deficiencies are identified.

The audit sub-element also requires the company to have an effective process for:

Evaluating the adequacy and effectiveness of the company’s management system;
Monitoring, measuring and documenting the company’s performance in meeting its obligations; and
Using an effective data management system to monitor and analyze the trends in hazards, incidents and near-misses.

The Board found that, at the program level, Enbridge’s Emergency Management department had processes for inspecting, monitoring and testing its emergency management program components. However, the Board found that Enbridge could not demonstrate that it had established and implemented governance management system processes that meet the requirements of the OPR.

As part of its review of this sub-element the Board conducted an evaluation of Enbridge’s management system and program level processes for taking corrective and preventive actions. The Board found that Enbridge had not established and implemented a management system process for taking corrective and preventive actions at both the management system and program levels that meets the OPR requirements. The Board notes that the requirement to have a process to take corrective and preventive action is included in many of the sub-elements within the Board’s audit protocol and the OPR. The Board therefore requires the corrective action plan developed to address the deficiencies identified for this sub-element to explicitly include all sub-element and OPR requirements, where corrective and preventive actions are referenced.

The Board found that Enbridge had established and implemented an emergency management exercise program to test and monitor it emergency response planning and capabilities.

The Board found that Enbridge has established and implemented a data management system that meets the Board’s requirements and provides a program level process to ensure that any corrective and preventive actions resulting from its emergency management testing and monitoring processes are appropriately managed.

Sub-element 4.2 - Investigating and Reporting Incidents and Near-misses

This sub-element of the audit requirements states that the company must establish and implement an effective process for reporting hazards, potential hazards, incidents and near-misses, and for taking corrective and preventive actions to address them. This includes investigating if the hazards, potential hazards, incidents and near-misses have or could have resulted in the safety and security of the public, employees and the pipeline, and protection of property and the environment. This sub-element also requires a company to have an established, maintained and effective data management system for monitoring and analyzing the trends in hazards, incidents and near-misses.

The Board found that Enbridge had developed and implemented the processes and procedures at the program level for documenting and investigating events that meet the OPR requirement.

The Board also found that, at the governance level, Enbridge’s IMS-01, section 4.10 Event Investigation Processes, dated 11-December 2013 had been documented and included in its Governing Policies and Processes Management System manual and that key activities were being implemented within its programs. These processes were, however, identified as “In Progress” and therefore not established and implemented.

Sub-element 4.3 - Internal Audit

This sub-element of the audit requirements states that a company must establish and implement an 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 Board found that Enbridge was undertaking many of the activities that are normally associated with quality assurance program. However, the Board found, however, that Enbridge had not organized the quality assurance activities within a program as required by the OPR.

The Board found that Enbridge had undertaken a number of audit related activities including an audit that meets the requirements of section 55 of the OPR. The Board also found that Enbridge had not undertaken an audit consistent with section 53 of the OPR. The Board noted that Enbridge had already developed a Board approved corrective action plan for this issue as part of its section 55 audit activities. The corrective action is scheduled to be completed by 31 December 2016.

With respect to developing a process for conducting audits as required by OPR section 53, Enbridge indicated that it utilized a combination of a number of different methods to meet these requirements. Upon reviewing the overall and individual processes and practices the Board found that they do not meet the OPR requirements by design and practice.

Sub-element 4.4 - Records Management

This sub-element states that a company must establish and implement an effective process for generating, retaining, and maintaining records that document the implementation of the management system and its protection programs.

The Board found that Enbridge had developed a draft governance Records Management Process as part of it Integrated Management System. The Board also found that, due to the draft nature of the process, Enbridge did not demonstrate that it had established and implemented a management system process that meets the OPR requirements.'

The Board also found that, regardless of the establishment of its management system process, Enbridge had implemented a consistent records management practice for application across its organization. At the Emergency Management program level the Board found record management process deficiencies with respect to the design and implementation in some of the document and records reviewed.'

Element 5.0 - Management Review

Sub-element 5.1 - Management Review

This sub-element states that a company must establish and implement an 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. This sub-element also requires a company to complete an annual report for the previous calendar year, signed by the accountable officer, describing the performance of the company’s management system in meeting its obligations.

The Board found that Enbridge had established and implemented processes to address the stated requirements and had undertaken the activities associated with its processes. The Board also found, however, that Enbridge’s processes did not fully meet all of the OPR requirements. As a result the management reviews completed by Enbridge were also found to be non-compliant.

Additionally, the Board found that some of the Non-Compliant findings made in this audit fall within the responsibility and accountability of Enbridge’s senior management. These relate to direction, management and oversight and, as such, have contributed to the Non-compliant finding for this element.

11.0 Conclusions

Companies regulated by the NEB must demonstrate a proactive commitment to continual improvement in safety, security and environmental protection. Pipeline companies under the Board’s regulation must establish and implement effective management systems and incorporate Emergency Management programs into their day-to-day operations. These programs must ensure that pipelines are operated in a manner that protects the environment.

During this audit Enbridge was required to demonstrate the adequacy and effectiveness of its management system and Emergency Management program to the Board. The Board reviewed documentation and records provided by Enbridge, conducted inspections and interviewed Enbridge staff.

Based on its review, the Board found that Enbridge was in a transitory period in terms of establishing and implementing its management system. Additionally, the Board’s audit found that some of Enbridge’s management system processes were not designed or established and implemented in a manner that allowed its management system to meet the requirements of OPR section 6.1. Consequently, the Board has found that Enbridge’s management system is Non-Compliant.

The Board has found that Enbridge’s Emergency Management program reflected the transitory nature of Enbridge’s management system and process issues as noted. The Board’s audit found, however, and most importantly, that, regardless of the design and implementation status of its management system, Enbridge’s Emergency Management program and the processes and practices being used, identified and controlled the majority and most significant of the company’s emergency management related hazards and risks.

In analyzing Enbridge’s Non-Compliant findings the Board has found that most of them fall into three general categories:

Non-compliances relating to management system process development;
Non-compliances relating to Enbridge’s interpretation of OPR requirements; and
Non-compliances relating to technical content

The Board notes that the majority of all of the Non-Compliant findings made by the Board relate to management system process development.

The Board has determined that while no enforcement actions are immediately required to address these non-compliant findings, as per the Board’s standard audit practice, Enbridge must develop and submit a corrective action plan describing its proposed methods to resolve the non-compliances identified and the timeline in which corrective actions will be completed. Enbridge will be required to submit its corrective action plan for approval within 30 days of the final Audit Report being issued by the Board.

The Board will assess the implementation of all of Enbridge’s corrective actions to confirm they are completed in a timely manner and on a system wide basis until they are fully implemented. The Board will also continue to monitor the overall implementation and effectiveness of Enbridge’s Emergency Management program and management system as a whole through targeted compliance verification activities as a part of its ongoing regulatory mandate.

The Board will make its final Audit Report and Enbridge’s approved corrective action plan public on the Board’s website.

Date modified:: 2021-09-15

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ARCHIVED – National Energy Board Onshore Pipeline Regulations (OPR) – Final Audit Report of the Enbridge Pipelines Inc. Emergency Management Program – OF-Surv-OpAud-E101-2014-2015 03

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Executive Summary

Table of Contents

1.0 Audit Terminology and Definitions

2.0 Abbreviations

3.0 Introduction: NEB Purpose and Framework

4.0 Background

5.0 Audit Objectives and Scope

6.0 Audit Process and Methodology

7.0 Audit Activities

8.0 Management System Evaluation

9.0 Program Summary

10.0 Summary of Audit Findings

Element 1.0 - Policy and Commitment

Sub-element 1.1 - Leadership and Accountability

Sub-element 1.2 - Policy and Commitment Statements

Element 2.0 - Planning

Sub-element 2.1 - Hazard Identification, Risk Assessment and Control

Sub-element 2.2 - Legal Requirements

Sub-element 2.3 - Goals, Objectives and Targets

Sub-element 2.4 - Organizational Structure, Roles and Responsibilities

Element 3.0 - Implementation

Sub-element 3.1 - Operational Control-Normal Operations

Sub-element 3.2 - Operational Control-Upset or Abnormal Operating Conditions

Sub-element 3.3 - Management of Change

Sub-element 3.4 - Training, Competence and Evaluation

Sub-element 3.5 - Communication

Sub-element 3.6 - Documentation and Document Control

Element 4.0 - Checking and Corrective Action

Sub-element 4.1 - Inspection, Measurement and Monitoring

Sub-element 4.2 - Investigating and Reporting Incidents and Near-misses

Sub-element 4.3 - Internal Audit

Sub-element 4.4 - Records Management

Element 5.0 - Management Review

Sub-element 5.1 - Management Review

11.0 Conclusions