ARCHIVED - National Energy Board Onshore Pipeline Regulations, 1999 (OPR-99) Final Audit Report for Integrity Management, Safety, Environmental Protection, Emergency Management, Crossings and Public Awareness Programs - Appendix V - Crossings Program Audit Evaluation Table

Appendix V
Spectra Energy Management Inc. as General partner
and Agent for Spectra Energy Empress L.P. (SET-PTC)
Crossings Program Audit Evaluation Table

Table of Contents

• 1.0 Policy and Commitment
  • 1.1 Policy and Commitment Statements
• 2.0 Planning
  • 2.1 Hazard Identification, Risk Assessment and Control
  • 2.2 Legal Requirements
  • 2.3 Goals, Objectives and Targets
• 3.0 Implementation
  • 3.1 Organizational Structure, Roles and Responsibilities
  • 3.2 Management of Change
  • 3.3 Training, Competence and Evaluation
  • 3.4 Communication
  • 3.5 Documentation and Document Control
  • 3.6 Operational Control-Normal Operations
  • 3.7 Operational Control-Upset or Abnormal Operating Conditions
• 4.0 Checking and Corrective Action
  • 4.1 Inspection, Measurement and Monitoring
  • 4.2 Corrective and Preventive Actions
  • 4.3 Records Management
  • 4.4 Internal Audit
• 5.0 Management Review
  • 5.1 Management Review

1.0 POLICY AND COMMITMENT

1.1 Policy and Commitment Statements

Expectations:

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

References:^{Footnote 1}

OPR-99 Sections 4, 47 and 48
CSA Z662-11 Clause 3.1.2

Assessment:

The PTC Pipeline has been operated by SET-PTC since 2005 and adheres to the Spectra Energy Transmission West (SET-West) environment, health and safety (EHS) policies and procedures. SET-West senior management participates in several committees that oversee the development and implementation of the policies that frame the EHS program. For the purposes of this audit, the SET-PTC’s third party crossings program (Crossings Program) is considered to be part of its Safety Program. The Safety Policy present at the field locations is signed off on by senior management. SET-PTC management communicates the policy for EHS programs through an Operational Steering Committee (OSC).

A review of the Policy states:

“To achieve our purpose we manage risk in everything we do, by continuously improving on :

• Employee, contractor and vehicle safety
• Process safety
• Environmental Management
• Reliability
• Cost management”

Although SET-PTC was able to demonstrate that its Policy is signed off on by senior management and communicated to employees, the audit found that a reference to public safety is not explicitly written into the purpose statement. Interviews confirmed that while staff members were familiar with the Policy, they could not identify the link between the Policy and public safety goals.

Due to the absence of public safety in the Policy, the current Policy at SET-PTC does not adequately support the Crossings Program. SET-PTC did not demonstrate that it prioritizes and mitigates the risks regarding its interactions with, and obligations to, third parties, and the public at large.

While it is understood that public safety is implied in the current policy, the heightened importance of public safety is underscored by its express reference in the National Energy Board Act (NEB Act) and associated regulations.

Compliance Status: Non-Compliant

2.0 PLANNING

2.1 Hazards Identification, Risk Assessment and Control^{Footnote 2}

Expectations:

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

References:

OPR-99 Sections 4(2), 37, 39, 40 and 41
CSA Z662-11 Clause 3.1.2(f)

Assessment:

As third party damage is considered a hazard, properly administered crossing applications and locates for third parties are crucial to protecting the pipeline from unintended third party damage.

SET- PTC uses a “Risk Watch” document to prioritize hazards to the pipeline system using criteria, and a progressive colour coding system (‘red-yellow-green’). Authored and managed by the SET-PTC Integrity Group, the Risk Watch lists the operational hazards and does not include hazards posed by third party activity. The Risk Watch process is owned by Operations engineering. The OSC discusses the risks, and then applies criteria to rank risks as red-yellow-green. Third party related activities are not incorporated into the Risk Watch. Instead, the hazard identification for third party crossing activity is incorporated and captured in the application approval process and safety instructions are outlined in crossing agreements.

Third party crossing requests for the PTC pipeline come into the SET-PTC Richardson Station office via facsimile from Saskatchewan First Call. The Business Analyst makes the required copies and passes all requests to the Public Awareness Coordinator for analysis. Based on this assessment, the applications that require engineering assessments are passed to the Integrity Group to complete the permit for the crossing. According to staff, the majority of the crossing requests it receives are in relation to another pipeline that runs parallel in a shared right-of-way. The technicians conduct pre-job safety meetings to discuss any hazards, and PTC staff is onsite for the crossing.

SET-PTC was able to demonstrate that it has implemented a process to identify and evaluate the hazards associated with third party crossings.

Compliance Status: Compliant

2.2 Legal Requirements

Expectations:

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

References:

OPR-99 Sections 4 and 6
Pipeline Crossing Regulations (PCR) Part II Sections 4 and 5
CSA Z662-11 Clause 3.1.2(h)(i)

Assessment:

SET-PTC receives legal updates requirements through the Regulatory Affairs group. The Regulatory Affairs group communicates regulatory changes via email to all groups. It is then up to the recipients on the distribution list to identify any changes that are relevant to their respective operational processes. According to staff, the Regulatory Affairs group also confirms deadlines for regulatory compliance such as the requirements of the NEB Exemption Order Respecting Crossings by Agricultural Vehicles or Mobile Equipment (Order). Document review showed that the legal requirements inventory kept at the SET-PTC office was last updated in 2009. There was no indication that recent updates, including those updates to the NEB Act or the Order, were identified and incorporated into this legal requirements inventory.

While the company was able to demonstrate that communication of regulatory requirements is occurring, and that current personnel are incorporating some new legal requirements into the procedures, SET-PTC did not demonstrate that there was an effective process to verify whether all appropriate legal requirements were incorporated into procedures and implemented as required.

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 Sections 47 and 48
CSA Z662-11 Clause 3.1.2(b)

Assessment:

Third party crossing activity goals are included under the Safety Program goals. SET-PTC sets performance based goals at various levels of the organization at annual area planning meetings. These goals are approved by the Operations Management System (OMS) Manager. An example of an annual corporate goal this year was for 100% of staff to complete core training by October 31. The goals and targets for employees are established in the employee development plans and monitored through a performance management process. Individual employee goals are then tied to the organization-wide Short Term Incentive Pay (STIP) Program.

According to the SET-PTC management, goals are set at the area planning meetings for the year that are related to its programs and risks. The PTC pipeline technicians also set a goal of completing a depth of cover survey for the whole pipeline in five years.

SET-PTC was able to demonstrate that there is a process for establishing goals, targets and objectives for its safety programs including its Crossings Program.

Compliance Status: Compliant

3.0 IMPLEMENTATION

3.1 Organizational Structure, Roles and Responsibilities

Expectations:

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

References:

OPR-99 sections 40, 47 and 48
CSA Z662-11 Clauses 3.1.2(b) and (c)

Assessment:

SET-PTC has seven staff members that perform a variety of crossing and facility maintenance activities. These staff report directly to the SET-PTC manager at the Richardson Station office in Saskatchewan. Although there has been an increase in crossing and facility maintenance activity with the construction of a major pipeline in close proximity to the PTC pipeline, PTC brings in contractors to assist with the increased workload with respect to crossing applications.

SET-PTC demonstrated that it has an organizational structure that allows it to effectively address the risks and hazards associated with the workload for the Crossings Program.

Compliance Status: Compliant

3.2 Management of Change

Expectations:

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

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

References:

OPR-99 section 6, CSA-Z662-11 Clause 3.1.2(g)

Assessment:

SET-West is in the process of implementing a comprehensive Management of Change (MOC) process for all SET-West affiliates, including SET-PTC. Interviews confirmed that SET-PTC will implement the MOC process being developed and implemented as part of the new OMS being introduced by SET-West to SET-PTC. The SET-West MOC Descriptions of Affected Applications, Systems, Documentation and Processes did not include the circumstances for involving the SET-PTC Crossing Program in the MOC process. Although there are aspects of a functioning asset-based MOC, and a more developed MOC is in development, at the time of the audit, SET-PTC failed to demonstrate that it has a comprehensive MOC implemented that includes process, resource or regulatory triggers to include an impact assessment of these changes on the Crossings Program.

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, 48 and 56
CSA Z662-11 Clause 3.1.2(c)(iii)

Assessment:

SET-PTC staff confirmed in interviews that they attend training that is tracked through the Learning Management System (LMS). All mandatory training is entered in the LMS database and the LMS notifies staff when re-training is due. Training required for the SET-PTC pipeline technicians includes both internally provided online training courses, as well as externally provided training for the locate equipment. As well, all employees involved in emergency response have Incident Command training. Annual performance reviews and staff development plans are managed in the Career Zone database and linked to the STIP Program.

Along with the core safety training, which all employees receive online, interviews confirmed that the SET-PTC pipeline technicians’ mandatory training includes Ground Disturbance Level I and II courses, all in order to conduct, supervise and inspect pipeline crossings. In order to perform pipeline locates for third parties, the pipeline technicians attend training provided by the locate equipment manufacturer to ensure that they are able to properly use and maintain the equipment.

While SET-PTC was able to demonstrate that it manages core skill training for staff involved in third party crossings, this training for pipeline technicians does not however, include training related to working with third parties.

As there is potential for the pipeline technicians to encounter third parties during various types of crossing-related activity, the audit determined that the pipeline technicians require training under the SET Violence in the Workplace policy, and related procedures for dealing with the public when interaction occurs.

Compliance Status: Non-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 and 29
CSA Z662-11 Clause 3.1.2(d)
PCR Part II Sections 4 and 5

Assessment:

Communication with external parties is managed in the SET-PTC Richardson Station office. SET-PTC pipeline technicians communicate with landowners regarding any proposed Operations and Management projects. SET-PTC sends letters to notify landowners of proposed upcoming work such as right of way maintenance. According to procedures, the day before the scheduled maintenance, the Pipeline Technicians contact the landowners by phone. The SET-PTC procedure dictates that they do not enter property before obtaining written permission from the landowner.

Organization wide safety-related communication takes place during mandatory safety stand down meetings and monthly mandatory safety meetings which are delivered to all sites simultaneously. There are also less formal town hall meetings to discuss safety topics which include third party issues such as call before you dig issues and agricultural practices. Employees also receive weekly safety reports by email that are posted on the Source and emails from Public Affairs.

SET-PTC was able to demonstrate that it has established regular communication within the Crossings Program as well as triggers for communicating with other teams such as operations and integrity. Although communication is occurring within Crossings Program, and there are triggers in place from the programs outward, SET-PTC failed to demonstrate that there is a fully implemented internal communication plan for the organization that includes the Crossings Program in order to ensure that relevant information is communicated in a timely way to internal stakeholders.

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 Section 27
CSA Z662-11 Clause 3.1.2(e)
PCR Part II Sections 10 and 11

Assessment:

SET-PTC employees store and use procedures and templates that are saved on the Source website. The Damage Prevention Group has created a webpage to post all of the forms, policies and related links for their group. If changes or enhancements are made to any of the procedures or templates, the SET-West (Westcoast) Crossing Administration and Damage Prevention Group uploads the new documents and announces the new versions by email to a distribution list of SET internal stakeholders. Interviews confirmed that SET-PTC staff is aware that all SET crossing-related procedures, templates and forms are available on the Source.

Although SET-PTC staff are aware of the Source documents, record review determined that SET-PTC staff continues to use old SET-PTC forms for locate requests and crossing records (SET-PTC locate/pre-work report). As well, review of a sample of crossing agreements showed that SET-PTC continues to use templates from its own local shared network drive and not the approved and updated SET permit templates from the Source. The use of older templates introduces the possibility that the records generated would not include or comply with recent updates to legal requirements or company program improvements. Without consistent review and updating, these forms and templates risk being inaccurate and not in compliance.

As noted in sub-element 2.2., SET-PTC did not demonstrate an effective process to verify whether all appropriate legal requirements were incorporated into procedures and implemented as required. Similarly, SET-PTC was unable to demonstrate that it has effectively implemented a document management process to ensure that when legal requirements or company standards have changed these changes are being incorporated into the forms and templates that it uses in the management of third party crossings.

Compliance Status: Non-Compliant

3.6 Operational Control-Normal Operations

Expectations:

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

References:

OPR-99 Sections 21 and 27-49
CSA Z662-11 Clause 3.1.2(h)
PCR Part II Sections 4 and 5

Assessment:

Requests for permission from third parties to excavate or construct near the pipeline are managed by the Public Awareness Coordinator and the Pipeline Manager at the Richardson Station office located in Saskatchewan. Complex crossing requests that meet the criteria for an engineering assessment are forwarded to the operations team. Once the request for permission has been processed and permits granted, the SET-PTC pipeline technicians visit the site to perform the locates for third parties and explain the locate markings to ensure that the crossing or installation can proceed safely. The pipeline technicians also attend, supervise and inspect third party crossings when required for safety reasons. According to staff, the third party crossing activity has increased in the area due to an increase in oil and gas related activity and the expansion of other pipeline systems in the area. This past year, the majority of the approximately 400 third party crossing applications came in from another pipeline company that is conducting construction and restoration work on its own right of way.

As it is required that installations or mechanical excavations in the zone that extends 30 metres from either side of the right of way to be done once written permission from the pipeline company is obtained, SET-PTC has implemented an on-site approval process. When a third party request for the installation of a facility such as a ditch or a fence comes in, and it meets the established criteria for requiring permission, but no assessment is warranted because of the distance from the pipe, SET-PTC technicians can issue onsite approval agreements to landowners/residents for installations such as fences. These agreements are kept on file at the Richardson terminal office.

Third party crossing requests along the Manitoba portion of the system are managed out of the Fort Whyte office. SET-PTC has a small staff responsible for crossing related work. As Manitoba does not have a one-call centre, any requests from third parties wishing to excavate or construct near the pipeline come in directly to the SET-PTC Fort Whyte office number. The pipeline technicians at Fort Whyte office manage between 20-30 crossing requests a year on average.

SET-PTC was able to demonstrate that it has the processes and procedures in place to manage and perform its crossing related duties.

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 (for example, after emergency events).

References:

OPR-99 Sections 32, 52
CSA Z662-11 Clause 10.5.2

Assessment:

The SET-PTC Public Awareness Coordinator coordinates the continuing education aspect of the emergency response training program. The SET-PTC pipeline technicians are trained in Incident Command and participate in emergency training sessions and table top exercises. Pipeline technicians are also on-call in case of emergencies. In order to be prepared to respond to a pipeline related emergency, the pipeline technicians carry current emergency response manuals in their company vehicles, and are on-call for emergencies on a rotating schedule.

Although the SET-PTC Emergency Management Program is discussed in further detail in Appendix IV of this audit report, the overlap of duties and substantial roles played by the pipeline technicians were reviewed and found to be in compliance with the Board’s regulatory expectations.

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 and 39
CSA Z662-11 Clause 3.1.2 (h)(i)
PCR Part II Sections 4, 5, 10 and 14(1)

Assessment:

The PTC pipeline is patrolled monthly by pipeline technicians who participate in the aerial right of way inspections where they look for unauthorized activities or encroachments. If any unauthorized activity is discovered, they report it to the Public Awareness Coordinator to address with the third party, and report to the NEB. Technicians in Manitoba also attend right of way patrols and are in the process of upgrading the signs and aerial markers when required. Reports are filed in the Richardson Station office.

Pipeline technicians also conduct inspections of third party crossings to ensure that safety instructions are being followed. This process also includes the inspection of the pipe prior backfilling when it is exposed during the course of a third party crossing to verify the condition of the pipe.

SET-PTC was able to demonstrate that it has the required surveillance and monitoring programs in place for the surveillance and monitoring of its right of way, as well as pipe inspections during third party crossings as required by the PCR.

Compliance Status: Compliant

4.2 Corrective and Preventive Actions

Expectations:

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

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

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

References:

OPR-99 Sections 6 and 52
CSA Z662-11 Clause 3.1.2 (h)(i)
PCR Part II Section 13

Assessment:

Regulatory non-compliances in respect of a crossing program, involve unauthorized activities performed by third parties. SET-PTC conducts regular right of way inspections to monitor for unauthorized excavation and construction activities that have occurred near its pipeline without permission. All of these unauthorized activities are reportable to the NEB under the PCR. According to SET-PTC staff, unauthorized activities are managed by the Public Awareness Coordinator. The Public Awareness Coordinator also manages and documents the response using the material created for the Public Awareness Program. Record review indicates that unauthorized activities are considered to be near misses and are entered into SET-PTC’s Incident Investigation System as incidents without loss and filed in the Richardson Station office in Saskatchewan.

SET-PTC demonstrated that it is identifying, reporting and investigating unauthorized activities.

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 41, 51, 52 and 56
CSA Z662-11 Clause 3.1.2(e)
PCR Part II Sections 10(c), 11(1) and 16

Assessment:

Records related to the Crossings Program include requests for permission, on-site approval agreements, and locate requests. SET-PTC Pipeline receives locate requests from Sask First Call by facsimile. Once the locate request is received, the office administer copies and files the request and passes it to the technicians. More complex requests are passed to the SET-PTC Manager for evaluation. SET-PTC manages all locate and inspection records in hard copy at the Richardson Station office for Saskatchewan, and the Fort Whyte office in Manitoba.

The SET-PTC Crossings Program relies on manual data entry into a spreadsheet and hard copy files in the office. According to staff, SET-PTC will be introducing an online system to improve and manage its records, which would allow for electronic access to all right of way related information from all sites.

While the SET-PTC records management continues to be managed manually using hard copy files, it was able to demonstrate that it has a records management procedure that allows its records to be retained, maintained and retrieved in accordance with regulatory expectations and requirements.

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 Section 53
CSA Z662-11 Clause 3.1.2 (h)(iii)

Assessment:

Senior management of Spectra Audit Services is located in Houston, Texas. However, an audit manager and several staff are located in Calgary, Alberta. Calgary-based audit staff perform most of the SET-PTC internal audits, sometimes with participation by Houston-based audit staff. These audits occur on a regular basis and vary in size and scope. All non-compliant findings are tracked in a database and assigned to staff for completion reported to senior management. However, interviews and document review confirm that these audits are conducted to measure SET-PTC’s compliance to its own internal program requirements and do not necessarily address its programs’ compliance to regulatory requirements.

While aspects of the SET-PTC operations are included in the internal audits, SET-PTC was not able to demonstrate that the Crossings Program and the requirements of the PCR have been scoped into any internal operational audits.

Also it did not demonstrate that the requirements of the PCR are included in its audit protocols for the audits regarding safety of the public in order to confirm compliance.

Compliance Status: Non-Compliant

5.0 MANAGEMENT REVIEW

5.1 MANAGEMENT REVIEW

Expectations:

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

References:

OPR-99 Section 53
CSA Z662-11 Clause 3.1.2 (h)(iii)
PCR Part II Sections 4 and 5

Assessment:

The manager of the PTC Pipeline meets with senior management annually to discuss resources and review accountabilities. As well, interviews and document review indicate that there is regular communication SET-PTC’s area management, operations management and senior management teams. SET-PTC’s senior management also holds meetings on a regular basis at different field locations to evaluate the operations of the pipeline and associated facilities.

While the Board acknowledges that there is communication occurring, SET-PTC was unable to demonstrate that it has established the required processes that contribute to an adequate management review. As noted in sub-element 2.2 of this appendix, SET-PTC does not have a formal process of confirming that there is a current and complete inventory of legal requirements guiding the development and implementation of its Crossings Program. Also, SET-PTC’s internal audit process does not include an evaluation of compliance to the PCR, which outline the requirements for addressing third party activities. Without this confirmation of compliance, senior management cannot verify that the Crossings Program is operating in compliance with all of the requirements. As well, SET-PTC’s policy and purpose statement does not explicitly include public safety, and so there is no clear line of sight from SET-PTC’s policy to the Crossings Program. Therefore the Board is not satisfied that there are sufficient processes in place by senior management to allow for a formal and documented management review to ensure ongoing suitability, adequacy and effectiveness of the Crossings Program.

Compliance Status: Non-Compliant

Date modified:

2020-09-29