ARCHIVED - Emera Brunswick Pipeline Company Ltd. - Audit Report OF-Surv-OpAud-E236 01 - Appendix II: EBPC Safety Program Audit Evaluation Table

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Appendix II
EBPC Safety Program Audit Evaluation Table

1.0 POLICY AND COMMITMENT

1.1 Policy and Commitment Statements

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

References:[1]
OPR-99 sections 4 and 7
CSA Z662-07 Clause 10.2.2
CLC Part II 125(1)(d)(i)-(ii), 125(1)(z.09)

Assessment:
Through the Operations and Maintenance Agreement (O&M), EBPC has adopted the Operator’s Environment Health and Safety (EHS) policy, performance standards and safety action plan. EBPC demonstrated that it had its own policy statement applicable to its facilities. Further, EBPC identified that as part of its management oversight of the facilities, it was comparing the policy with that of the Operator to ensure consistency.

The EHS policy includes the following principles:

  • Accountability
  • Stewardship
  • Standards
  • Performance
  • Communication

The EHS Management System (MS) outlines how employees and contractors are expected to meet the desired level of EHS performance for the following elements:

  1. Roles, responsibilities and accountabilities
  2. Risk management
  3. Emergency Preparedness & Response
  4. Compliance management
  5. Supplier, Contractor and Partner Relationships
  6. Stewardship and community relations
  7. Goal setting and performance measurement
  8. Incident reporting and investigation
  9. Assessment and management system review

Based on interviews and documents reviewed, the Board verified that EBPC has adopted the Operator’s EHS MS and that the commitment to managing its safety hazards and risks was visible at all levels within the organization.

Compliance Status: Compliant

[1] Each “Reference” in this table contains specific examples of the “legal requirements” applicable to each element but are not necessarily a complete list of all applicable legal requirements.

2.0 PLANNING

2.1 Hazards Identification, Risk Assessment and Control[2]

Expectations: The company shall be able to demonstrate a procedure to identify all possible hazards. The company should assess the degree of risk associated with these hazards. The company should be able to support the rationale for including or excluding possible risks in regard to its environment, safety, integrity, crossings and awareness and emergency management and protection programs (management and protection programs). The company should be able to implement control measures to minimize or eliminate the risk.

References:
OPR-99 sections 4(2) and 47
CSA Z662-07 Clause 10.2, 10.3.2
CLC Part II 125.(1)(s)(z.03)-(z.05), 125(1)(z.13)-z.16)
COSHR 19.1(1), 19.3(1)-(2), 19.5(1)-(5)

Assessment:
As part of an O&M Agreement between EBPC and its Operator, the Operator is implementing and maintaining the EHS MS.

The Operator uses a Risk Inventory and Job Safety Analysis (JSA) to assess EHS risk for various duties. The risk inventory method involves discussions with EHS, Operations, Maintenance, and other site personnel around specific scenarios. For each identified scenario, the team discusses how workers could be injured or the environment damaged and then critically evaluates adequacy of existing controls. The JSA method integrates risk assessment and control to the particular task completed in order to identify controls at specific locations.

It was confirmed during field verification that the Operator incorporates existing procedures for completing Job Hazard Assessments; Hazard Identification and Reporting forms; Job Observation Checklists. Risk assessment workshops are held annually to support the risk management element of the EHS MS by establishing a forum to identify and evaluate EHS risks. Prior to the workshop, EHS personnel obtain feedback from across the organization, by interviewing a broad range of personnel. This data was used as the basis for the workshop.

In order to manage risks to contractors, the Operator has a health and safety management performance standard. This standard provides guidance for the registration, selection and oversight of all contractors performing work on the Brunswick Pipeline. A review and evaluation of contractor’s health and safety work and communication plans are developed in advance of the work to ensure they are appropriate to the risks of the work. This review ensures adequate internal and external oversight controls are part of the project review. It was confirmed during document review and interviews that various methods of communicating the EHS requirements to employees and contractors are in place. Upon the completion of the contract, contractor performance is reviewed and documented.

The Operator was able to demonstrate through document review and interviews that hazard identification, risk assessments and controls are being conducted throughout the organization.

Compliance Status: Compliant

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

2.2 Legal Requirements

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

References:
OPR-99 sections 4, 6 and 47
CSA Z662-07 Clause 10.2.2(g)
CLC Part II 125.(1)(v)
COSHR 19.1(1)

Assessment:
As part of an O&M Agreement between EBPC and its Operator, the Operator is responsible for developing, implementing and maintaining the EHS MS.

During the audit it was identified that the Operator has developed a process which includes the identification and status of regulatory requirements and undertakings. An annual review is conducted of Standard Operating Procedures (SOPs) to ensure legislated requirements are met and a gap analysis is conducted by the Operator’s United States (U.S.) based staff to determine any next steps which may be required. The Director, Regulatory Affairs & Government Relations is the primary point of contact with the NEB with regard to any compliance issues or changes to regulatory requirements. Upon receiving notification/correspondence from the NEB, the Director, Regulatory Affairs & Government Relations forwards this information to the Operator as appropriate. Safety compliance issues and identified gaps are tracked within the appropriate management team of the operator as well as by the EHS Department and monitored by EBPC.

Regardless of the development and intent of the processes described above, the Operator was unable to demonstrate the processes were being consistently implemented. During the audit, the Operator was not able to demonstrate that its processes included all of the Canadian OHS legislation which applied. For example, it was noted during document review and interviews that the Canada Labour Code Part II (CLC Part II) and the Canada Occupational Health and Safety Regulations (COSHR) were not included in any of the reference documents, making it difficult to verify whether the relevant requirements had been identified and integrated into these documents. As another significant example, at the time of the audit, the Operator was not able to demonstrate that it has a process that would meet the requirement to develop and implement a “Violence Prevention in the Workplace” program as required by CLC Part II 125.1(z.16) and COSHR Section 20 which came into effect in 2008 (SOR/2008-148, s. 1). Interviews with the Operator’s Human Resources personnel confirmed that the 'Violence in the Workplace Policy and Program' is currently under development; however, as the program was in the early stages of development, it could not be assessed for adequacy.

The Operator did not demonstrate that it has an effective and fully implemented process to identify and integrate all appropriate occupational health and safety legislation into its Safety Program.

Compliance Status: Non-compliant

2.3 Goals, Objectives and Targets

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

References:
OPR-99 section 47
CSA Z662-07 Clause 10.2.2(h)(ii)
COSHR 19.1(1)

Assessment:
As part of an O&M Agreement between EBPC and its Operator, the Operator is implementing and maintaining the EHS MS.

The EHS policy contains safety principles for the EHS MS. Action plans and objectives are set out by the Operations Committee, EHS Committee, management and staff personal safety action plans. The membership of the Operations Committee and the EHS Committee consists of Vice Presidents of the various divisions. The committee provides reports/updates to senior management to provide a clear picture of the work of the committees.

Employee objectives are discussed with their supervisor at the beginning of the year, at least once during the year and again at the end of the year when the past year’s performance is evaluated and objectives are established for the next year. Safety goals, targets and objectives have been identified for all staff and are included in individual job descriptions. Safety performance is included in the overall employee objectives and employees are provided recognition in meeting its EHS performance objectives known as the “Short Term Incentive Programs”.

The Operator was able to demonstrate through documents and interviews that objectives and targets have been set relevant to its safety hazards and risks.

Compliance Status: Compliant

3.0 IMPLEMENTATION

3.1 Organizational Structure, Roles and Responsibilities

Expectations: The company shall have an organizational structure that allows its management and protection programs to effectively function. The company should have clear roles and responsibilities, which may include responsibilities for the development, implementation and management of the management and protection programs.

References:
OPR-99 section 47
CSA Z662-07 Clauses 10.2.1 and 10.2.2(b)
CLC Part II 125(1), 125.1, 134.1, 135(1)

Assessment:
As part of an O&M Agreement between EBPC and its Operator, the Operator is implementing and maintaining the EHS MS.

Overall accountability for EHS issues is maintained by the Environment Health and Safety Committee (EHSC), which is comprised of senior personnel as well as representatives from the Board of Directors. Quarterly EHS reports are reviewed by the EHSC. An EHS Management Team has been established with specific accountabilities for safety. The Board reviewed copies of job descriptions to confirm that specific safety-related responsibilities and accountabilities are identified.

Lines of reporting for safety issues are clearly outlined, and include reporting routes from the Operator’s Vice President, Operations Northeast (NE) Transmission; Manager, NE-Health & Safety; and the EHS Support Specialist. The other line of reporting includes the Director EHS, Houston.

Following interviews and reviews of job descriptions, the Board identified one concern regarding the expectations of the role of the EHS Support Specialist. The workload for this senior position appears to be significant for one person to manage. It was noted that the safety management workload involved review and development of new practices and procedures and included oversight of activities involving contract management and on-sight activities.

The Board recommends that the Operator review the responsibilities of the EHS Support Specialist to ensure that environmental and safety protection is maintained and can remain effective.

Compliance Status: Compliant with recommendation

3.2 Management of Change

Expectations: The company shall have a management of change program. The program should include:

  • identification of changes that could affect the management and protection programs;
  • documentation of the changes; and
  • analysis of implications and effects of the changes, including introduction of new risks or hazards or legal requirements.

References:
OPR-99 section 6
CSA Z662-07 Clause 10.2.2 (g)
CLC Part II 125.(1)(z.05)-(z.06)
COSHR 19.5(4), 19.6(2)

Assessment:
In regard to technical changes, EBPC indicated that it defers to the Operator as part of managing operations outlined in the O&M agreement. The Operator demonstrated that it has a Management of Change (MOC) procedure in place which outlines the process to be followed for identifying, assessing and implementing changes once they have been approved by the responsible individuals (EHS MS Management of Change Performance Standard 2.7).

Currently, the Operator staff is participating in a collaborative process to review all operational SOPs against all regulatory requirements and best practices (Canadian and U.S.). EHS is leading the process with support of Senior Management, and Regional subject matter experts.

The MOC process is partially implemented by various disciplines and programs within the organization. However, at the time of the audit, there was no evidence provided to demonstrate a fully documented and implemented MOC program.

The Operator could not demonstrate an adequate MOC for oversight of its activities or that there is an adequate fully implemented MOC process in place for EBPC facilities and activities to identify, document and analyze changes that could affect the EHS MS, including introduction of new risks, hazards or legal requirements.

Compliance Status: Non-compliant

3.3 Training, Competence and Evaluation

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

References:
OPR-99 sections 28, 29, 30(b), 46, 47 and 56
CSA Z662-07 Clause 10.2.2(c)
CLC Part II 124, 125(1)(q), 125(1)(s), 125(1)(z), 125(1)(z.01), 125(1)(z.03)
COSHR 10.14, 11.5(2), 11.11, 12.10(1.1)(a)(ii), 12.10(1.2), 12.15, 13.11, 14.23, 17.6(1), 20.10, 19.1(1), 19.2(2), 19.6

Assessment:
According to the O&M agreement between EBPC and the Operator, the Operator is responsible for training of employees. The Operator has developed a safety training matrix that applies to employees assigned to operating and maintaining the Brunswick pipeline. This matrix consists of a list of core safety training courses and the frequency with which they are required. Some of the mandatory safety training is delivered online. Document review confirmed that the Operator maintains records of all training required and completed by all workers. Employees are provided with any updates to this matrix should additional training requirements be identified or should existing curriculums be changed. The Board also reviewed the Human Resources Orientation checklist which includes a safety training component that requires manager’s sign off.

The Operator was able to demonstrate that it has an adequate and effective safety training program which ensures employees are able to fulfill their roles and responsibilities.

Compliance Status: Compliant

3.4 Communication

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

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

References:
OPR-99 sections 18, 28, 29 and 47
CSA Z662-07 Clause 10.2.2(d)
CLC Part II 122.3(1)-(2), 125(1)(d)-(f), 125(1)(s), 125(1)(z.03)-(z.11), 125(1)(z.14)-(z.15), 125(1)(z.17),-(z.19)

Assessment:
As part of an O&M Agreement between EBPC and its Operator, the Operator is implementing and maintaining the EHS MS.

The Operator was able to demonstrate that it employs many methods for communicating safety requirements with its internal and external stakeholders. Communication of safety information takes place during safety stand down meetings; quarterly employee meetings and safety updates; daily tailgate meetings; daily and weekly safety reports; NE Region Health and Safety Newsletters; monthly safety and communications meetings; monthly reports to EHS Corporate group; contract management activities, pre-job meetings, its intranet sites; etc.

Although there are several communication mechanisms in place, the Operator could not demonstrate that there is a formalized and implemented overarching communication plan that outlines the distribution of various types of information to appropriate parties. While interviews confirmed communication is occurring throughout technical networks and through the means identified above, without a formal communication plan, the Operator cannot ensure that all stakeholders and interested parties are receiving the appropriate information in a timely fashion.

Despite the documented communication which takes place during the various meetings. Within the safety program, the Board could not verify that a formalized communication plan exists within the organization that clearly identifies interested parties and pertinent safety information that is required to be communicated.

Compliance Status: Non-compliant

3.5 Documentation and Document Control

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

References:
OPR-99 sections 27, 47 and 56
CSA Z662-07 Clause 10.2.2(e)(f)
CLC Part II 125(1) (z.03)-(z.06), 125(1) (z.09), 125.1(d)-(e), 125.1(f), 135.1(9)
COSHR 1.5, 2.23, 4.6, 5.17, 5.18, 8.12, 8.14(4)-(7), 8.15, 10.3

Assessment:
As part of an O&M Agreement between EBPC and its Operator, the Operator is implementing and maintaining the EHS MS which includes the management of operational documents and manuals.

It was confirmed that a comprehensive document management system is in place, which includes control and transmittal tracking of all safety related documents. The Board was able to verify that the document management system undergoes continual monitoring, evaluation and updating of documents when required.

However, during the document review, version control issues with selected safety program documents were identified. For example, although not the most current version of the standard, CSA Z662-03 was referenced in procedures throughout the Operations and Maintenance Manual. There was no evidence suggesting that the outdated reference was indicative of a systemic issue as the Integrity Management Program Manual and the Emergency Preparedness Manual referenced the CSA Z662-07.

It is recommended that the Operator update the Operations and Maintenance Manual to reflect the current CSA standard. This reference update ensures that users of the document can trace a requirement as referenced in the manual and obtain the most up-to-date requirements.

The Operator was able to demonstrate that it has adequate documentation and controls in place to ensure that the EHS MS provides the appropriate level of guidance to employees.

Compliance Status: Compliant with recommendation

3.6 Operational Control - Normal Operations

Expectations: The company should establish and maintain a process to develop, implement and communicate mitigative, preventive and protective measures to address the risks and hazards identified in elements 2.0 and 3.0. The process should include measures to reduce or eliminate risks and hazards at their source, where appropriate.

References:
OPR-99 sections 27-49
CSA Z662-07 Clauses 10.2.2(f) and 10.3.1
CLC Part II 125.(1), 125.1
COSHR 19.1(1)

Assessment:
As part of an O&M Agreement between EBPC and its Operator, the Operator is implementing and maintaining the EHS MS.

The Operator uses a Health and Safety Standards Manual that contains procedures for controlling identified risks associated with tasks typically encountered by operations personnel. The procedures reference and acknowledge compliance with applicable legislation and with industry association best practices.

The audit confirmed that the risk assessment and Job Hazard Analysis that have been completed include various mitigating measures. These identified measures then form the basis of the procedures to ensure operational control is maintained.

An Operations Control Table is being developed by the Operator to provide procedural consistency across the business units. The Operations Control Table will be used in conjunction with the EHS Risk Registry Guide. The EHS Risk Registry provides a centralized summary of risk scenarios for review by Business Unit Leadership in setting priorities and allocating resources to adequately manage the EHS element of operational risk. Also the SOP harmonization project, which is underway to revise all SOPs against regulatory requirements and best practices (Canadian and U.S.), will be implemented to ensure all operations and maintenance activities are executed in compliance with the most stringent regulations and standards.

The Operator was able to demonstrate that it has a process to identify and reduce or eliminate hazards as appropriate.

Compliance Status: Compliant

3.7 Operational Control - Upset or Abnormal Operating Conditions

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

References:
OPR-99 sections 32, 35 and 52
CSA-Z662-07 Clause 10.3.2
CLC Part II 125(1)(o)
COSHR 17.4, 17.5, 19.1(1)

Assessment:
EBPC, in conjunction with the Operator, has developed and implemented an Emergency Preparedness and Response Plan. It was verified that worker safety issues associated with the emergency evacuation and muster locations are discussed during orientations and fire evacuation procedures are posted and tested to ensure the effectiveness of the safety measures. Emergency evacuation drills and mock exercises are held on a regular basis.

For more details on the Emergency Preparedness and Response Plan as it relates to the expectations of OPR-99, see Appendix IV: EBPC EPR Program Audit Evaluation Table.

Compliance Status: Compliant

4.0 CHECKING AND CORRECTIVE ACTION

4.1 Inspection, Measurement and Monitoring

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

References:
OPR-99 sections 36, 39, 47, 53(1) and 54(1)
CSA Z662-07 Clauses 10.2.2 and 10.14.1
CLC Part II 125(1)(c), 134.1(4)(d), 135(7)(k), 136(5)(g), 136(5)(j)
COSHR 4.5, 4.6, 5.10, 6.10(3), 10.18, 12.3, 12.14, 14.20, 14.21, 14.23, 15.6, 17.3, 17.9

Assessment:
As part of an O&M Agreement between EBPC and its Operator, the Operator is implementing and maintaining the EHS MS.

As indicated in other sections of this report, the Operator is holding various meetings and completing reports which monitor and document the EHS MS safety component, including:

  • Daily and monthly progress reports;
  • Daily and weekly safety inspection reports;
  • Daily tool box meetings;
  • Weekly all staff meetings;
  • Weekly fire drills;
  • Weekly behaviour based inspections;
  • Incident reporting;
  • Incident investigation when required; and
  • Completion of Incident Without Loss (IWOL) tracked on Environment Performance and Safety System (EPASS).

Document review confirmed that actions resulting from the above listed activities are assigned and tracked to ensure any issues are addressed and reported.

The Board verified that the Operator has adequate processes in place to monitor and measure its safety program. The Board recommends that the Operator consider this information during the development of the formal communication plan (see Element 3.4).

Compliance Status: Compliant with recommendation

4.2 Corrective and Preventive Actions

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

The company shall demonstrate that it has established a documented procedure to:

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

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

References:
OPR-99 sections 6 and 52
CSA Z662 Clauses 10.2.2(g) and (h)
CLC Part II 125(1)(c), 125(1)(o), 125.1(f),134.1(4)(d), 135(7)(e), 135(7)(j), 136(5)(g)
COSHR sections 2.27, 7.3, 10.4, 10.5, 15.4, 19.1(1)

Assessment:
As part of an O&M Agreement between EBPC and its Operator, the Operator is implementing and maintaining the EHS MS.

The Operator has developed and implemented a comprehensive incident investigation process is in place. The incident reporting and investigation process includes significant near misses and includes contractors in incident investigations, when appropriate. The investigation process identifies root causes and trends that lead to corrective and preventive action. The Operator tracks the actions until completion and verifies their effectiveness. Incidents are analyzed to detect patterns or trends to anticipate and prevent future incidents. The incidents and accidents are recorded and reported as per policy. Best practices and lessons learned are shared with others who can benefit.

The Board verified that the Operator has adequate processes to ensure safety related incidents are investigated and the appropriate measures are taken to correct or prevent further deficiencies in its execution of the EHS MS.

Compliance Status: Compliant

4.3 Records Management

Expectations: The company shall establish and implement procedures to ensure that the records supporting the management and protection programs are retained, accessible and maintained. The company shall, as a minimum, retain all records for the minimum lengths of time as required by the applicable legislation, regulation and standards incorporated by reference into the regulation.

References:
OPR-99 sections 47 and 56
CSA Z662-07 Clause 10.2.2(e)
CLC Part II 125(1)(g), 1.5, 2.23, 2.24, 2.27(7), 4.6
COSHR 5.17, 5.18, 6.10(7), 7.3(6), 8.18(7), 10.6, 10.15, 10.19(4), 11.12, 12.14, 14.23(4), 15.11, 16.13(2), 17.4(4), 17.8(2), 17.9(2), 17.10(2), 18.39, 18.40, 18.41, 18.42, 19.6(5), 19.8(2)

Assessment:
As part of an O&M Agreement between EBPC and its Operator, the Operator is implementing and maintaining the EHS MS.

It was confirmed through documentation and record review that both EBPC and the Operator have implemented record retention processes which include appropriate types of records to be retained, retention and disposition timeframes and disposal methods. Copies of all records requested were made readily available. The Operator maintains safety and incident data using its EPASS system with hard copy records being maintained in the regional offices.

Compliance Status: Compliant

4.4 Internal Audit

Expectations: The company shall develop and implement a documented process to undertake audits of its management and protection programs and procedures. The audit process should identify and manage the training and competency requirements for staff carrying out the audits. These audits shall be conducted on a regular basis.

References:
OPR-99 sections 53 and 55
CSA Z662-07 Clauses 10.2.2(c) and (h)(iii)
COSHR 19.7(1)(2)

Assessment:
As part of an O&M Agreement between EBPC and its Operator, the Operator is implementing and maintaining the EHS MS.

During interviews, staff indicated that Operator’s internal safety audits are conducted by the Operator’s Manager, Internal Audits. The audit planning cycle is determined by a comprehensive risk assessment. The 28 September 2009 EHS MS audit commissioned by the Operator was reviewed along with the audit response report which shows the progression of remedial action to address non-compliances identified in the audit. Remedial action is tracked in the EPASS system to ensure actions items are closed-out. To ensure all legislated responsibilities are included, local subject matter experts are contracted to ensure appropriate legislation is included for the facilities being audited.

It is recommended that the Operator choose an appropriate audit schedule and complete an internal audit of the safety of its operations and maintenance activities in the near future.

Compliance Status: Compliant with recommendation

5.0 MANAGEMENT REVIEW

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

References:
OPR-99 section 55
CSA Z662-07 Clause 10.2.2(h)(iii)
COHSR sections 11.2(4), 12.10(1.2), 19.6(3), 19.7(1)-(2)

Assessment:
See Appendix VII for the assessment of this element.

Compliance Status: See Appendix VII for the assessment of this element.

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