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Appendix I

Environmental Protection Program Audit Evaluation Table^{Footnote i}

1.0 POLICY AND COMMITMENT

1.1 Leadership Accountability

Expectations:

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

References:

OPR section 6.2

Assessment:

Accountable Officer

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

On 31 March 2014, Enbridge submitted written notice to the Board indicating that its President, Guy Jarvis, had been appointed as the accountable officer for Enbridge Pipelines Inc. and all of its subsidiaries regulated by the Board. In its submission, Enbridge confirmed that it’s accountable officer has the authority over the human and financial resources required to meet the Board’s substantive expectations.

Summary

Based on the Board’s evaluation of Enbridge’s management system and Environmental Protection program against the requirements, the Board has not found any issues of Non-Compliance. The Board has determined that Enbridge is Compliant with this sub-element.

Compliance Status: Compliant

1.2 Policy and Commitment Statements

Expectations:

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

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

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

References:

OPR section 6.3

Assessment:

Governance Level Policies and Goals and Commitment Statement

The Board requires the company to document its policies and goals for ensuring its activities are conducted in a manner that ensures the safety and security of the public, workers and pipeline, and the protection of property and the environment.

The NEB OPR does not include any specific management system process requirements for developing policies and goals. However, Enbridge has established clear management system guidance with respect to its process for developing policies and goals. At a governance level, Enbridge’s IMS-01, Governance Documentation outlines the company’s expectations for documenting key corporate policies, such as the Strategic and Business Planning Processes. The Governance Documentation also explains the company’s “Planning Cascade” and associated documentation. This Planning Cascade document explains how the company links its policies and corporate vision to its performance targets and metrics. The practices described within the Governance Documentation process align with the Board’s requirements for establishing policies, goals, objectives, targets and performance measures. While not an absolute alignment between the Board’s requirements and Enbridge’s internal processes it does reflect integration of the Board’s requirements into Enbridge’s business management practices.

(Note: While “goals” are included in this sub-element’s description, for clarity and organization, the review of goals is documented in sub-element 2.3 Goals, Objectives, Targets, below)

Governance Policy

Enbridge’s IMS-01, section 4.2.1, Strategy and Objectives Development Process describes the company’s process for establishing objectives, setting targets, and maintaining a dashboard of scorecard metrics. The executive management team uses the Strategy and Objectives Development Process to direct department priorities and activities. Section 4.3.2, Scorecard and section 4.3.4, Dashboard Reporting Process define the departmental processes for monitoring and measuring its performance against the Liquids Pipelines Business Plan and Enbridge targets.

Governance Commitment Statement

With respect to the OPR requirements relating to developing “a policy statement that sets out the company’s commitment to these policies and goals and shall communicate that statement to the company’s employees”, the Board identified that Enbridge’s IMS-01 included a compliant statement signed by the company’s Accountable Officer. The Board noted that this statement had not been updated in the documents it received at the time of the audit. The Board notes, however, that the documents were provided to the Board before the company notified the Board of its new Accountable Officer. Therefore, the Board will not be making a Non-Compliant finding based on this lack of endorsement.

(Note: During its audit the Board noted that Enbridge’s Management and Protection Programs are directed by its Governance Management System Processes; therefore, a full review of the Governance Processes and their application at the “program” level follows.)

Environmental Protection Program Policy and Commitment Review

Environmental Policy

Enbridge’s Environmental Management System (EMS) falls within its IMS. IMS-06, dated 5 June 2013, contains the Liquids Pipelines Environmental Policy. In this policy, Enbridge commits to complying with government regulations and standards through internal rules and procedures for environmental protection that will be consistent with industry codes and guidelines.” Interviews with company representatives at all levels revealed a consistent awareness of the Environmental Policy and a clear understanding of its intent.

Hazard Reporting and Immunity from Disciplinary Action Policies

The OPR contains specific policy requirements with respect to internal reporting of hazards, potential hazards, incidents and near-misses that includes the conditions under which a person who makes a report will be granted immunity from disciplinary action. The Board expects this policy to be explicit in its design and communication and be easily visible to all staff.

In its demonstration of compliance with these OPR requirements, the Board was provided a number of internal documents that describe Enbridge’s expectations with respect to the required policy. The documents provided included its IMS-01: Governing Policies and Processes, its IMS-02: Compliance and Ethics Management System, its Compliance Policy, its Statement of Business Conduct and numerous Tier 2 and 3 documents. The Board reviewed the documents and noted the following:

Enbridge’s IMS-01, Governing Policies and Processes Management System was released on 1 January 2014. This document is the foundation for the management systems that were being developed and implemented at the time of the audit. The Compliance Assurance section in IMS-01 states that “management will provide an open and confidential method for the Workforce to report Non-Compliant, unethical or unlawful behaviour, without fear of retaliation.”

Section 1.4.3 of IMS-02, states that “The Enbridge Workforce will report to their supervisor situations and acts they suspect could reveal or lead to an Event affecting Enbridge. No retaliatory action will be taken against any Workforce member raising Events in good faith. Raising Events will be held confidential, in accordance with legal requirements.” Further, IMS-02, section 1.5 states that “Events will be reported without fear of retaliation to ensure Corrective and Preventive Action.”

Enbridge has posted the Compliance Policy for its Liquids Pipeline division on its e-link intranet site. This policy says that employees are accountable to “comply with all applicable laws, regulations and other legal requirements.” According to this policy, employees are expected to “immediately report any new or suspected material compliance issue to their leader.” The policy also says that “in reporting any new or suspected compliance issues all employees will be treated in accordance with Enbridge’s non-retaliation principles set out in Enbridge’s Statement on Business Conduct.”

The Statement of Business Conduct applies to all employees and contract staff in the Enbridge group of companies. The statement includes Enbridge’s non-retaliation policy. It includes the assertion that “no retaliatory action will be taken against an employee or contractor for providing good faith information either internally or to a government authority, or for participating in any proceeding concerning alleged violations of any laws of policies. Disciplinary measures may be taken against an employee or contractor if they participated in the activity, even if they reported it.”

Review of the supplied information identified that the Enbridge policies did not explicitly include reporting of hazards and potential hazards. The policies also did not explicitly identify the conditions under which a person who makes such a report will be granted immunity as part of the reporting policy. Further, Enbridge limited its non-reprisal statements to issues relating to compliance or unethical behavior. The Board notes that the policies are intended to be explicit with respect to reporting and what to report in order to, not only encourage reporting but also to clearly identify what to report. Enbridge’s statements would require interpretation prior to reporting thus potentially slowing down hazard management and mitigation. Also, as hazards and potential hazards are not necessarily violations of law or the result of unethical behaviour, the Board has determined that the policies or statements provided did not meet the OPR requirements. Further, the Board finds that Enbridge did not communicate the policy requirements in a manner acceptable to the Board. The Board found that many parts of the requirements were located in intranet documentation or in Tier 2 and 3 documents. The Board considers that the required policy should be part of the corporate policy and be communicated explicitly as such.

Summary

The Board found that Enbridge has developed and communicated Environmental Protection policies applicable to its activities that had been communicated and integrated within the company’s activities.

The Board found that Enbridge has stablished clear management system guidance with respect to its process for developing policies and goals.

The Board found that Enbridge has developed a policy statement that sets out the company’s commitment to these general policies and goals and has communicated the its employees

The Board also found that Enbridge has not established an explicit policy with respect to internal reporting of hazards, potential hazards, incidents and near-misses that includes the conditions under which a person who makes a report will be granted immunity from disciplinary action that meets the Board’s requirements.

Based on the Board’s evaluation of Enbridge’s management system and Environmental Protection 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.

Compliance Status: Non-Compliant

2.0 PLANNING

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

Expectations:

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

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

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

References:

OPR section 6.5(1)(c)(d)(e)(f)(r)(s)

Assessment:

Governance Level Hazards and Potential Hazards Identification

At a governance level, Enbridge’s IMS-01, section 4.3, Risk Management Process describes the company’s process for identifying hazards, assessing risks and developing and implementing controls. The process includes written descriptions and the steps required for identifying hazards, assessing risks, planning risk responses, monitoring, reviewing and reporting risks. At a high level, the risk management steps identified in Enbridge’s Risk Management Process correspond to the legal requirements of this sub-element. However, in its review of this process, the Board noted deficiencies in the design and implementation of this process.

Enbridge’s Risk Management Process outlines broad, inter-related requirements and commitments; however, it does not meet the Board’s process requirements as outlined in Section 1.0 Audit Terminology and Definitions of the Board’s attached Audit Report.

Governance: Hazard vs Risk

In the governance Risk Management Process and related practices, Enbridge uses the terms “risk” and “hazard” interchangeably; this is inconsistent with the Canada Labour Code and the OPR and common practice definition or use of the terms. The Board has provided the following definition of hazard and risk in the past. Hazard: Source or situation with a potential for harm in terms of injury, ill health, damage to property, damage to workplace and environment, or a combination of these. Risk: Combination of the likelihood and consequence(s) of a specified hazardous event occurring.

Although the Board reviewed Enbridge’s program with this terminology issue in mind, the discrepancy has led to some gaps being identified in the overall Risk Management Process.

Governance Hazards Inventory

Enbridge’s governance Risk Management Process requires that each sub-ordinate management system develop risk registers which is non-compliant with the requirements of OPR both in name and intent. The Board requires companies to develop an inventory of identified hazards and potential hazards.

Governance Risk Evaluation

Enbridge’s governance Risk Management Process includes a risk evaluation practice within it. The Board reviewed Enbridge’s Risk Evaluation practice. The method used to evaluate the risk of hazards (Enbridge - risks) was fully developed and appropriate if it was implemented as designed.

The Board’s audit also assessed the implementation of the risk evaluation process. This assessment determined that, while it was being implemented consistently across all of Enbridge’s programs, it was being utilized in a manner inconsistent with OPR requirements. Through interviews and document and record reviews, it was determined that Enbridge was implementing a practice whereby it applies the risk evaluation process to risks (hazards) taking into consideration the controls that may apply to the risk prior to the assessment. The result of this practice would be the identification of “residual” risk and assumes that the controls are directly applicable and appropriate to the hazard and that the control is being implemented fully on a consistent basis. The OPR process indicates that the risk evaluation should be applied directly to the hazard. This will determine “inherent” risk. This allows companies to fully identify the significance of the hazard and appropriately communicate, establish and implement controls and monitor it as required in the OPR.

In evaluating the establishment and implementation of the Enbridge’s Risk Management Process, the Risk Management Process Map provided in IMS-01 section 4.3, was noted to contain process steps that were colour-coded red and yellow. According to Enbridge, yellow colour coding indicates that the activities required to execute the process step are not adequately documented or not fully implemented in a consistent manner. Red colour coding indicates that the process step is aspirational and is not being executed by the organization. Several process steps within the Risk Management Process Map were colour coded red yet are regulated requirements within the overall Risk Management Process. For example, process step 16 - “identify, assess and prioritize risks” is a process step that is required to meet the requirements of OPR section 6.5(1)(e). The Board has previously communicated that it recognizes aspirational practices as part of sound continual improvement practices. If a company clearly demonstrates that its practices are above the legal requirements and proactively communicates them as such within its overall programs, the Board will not find them non-compliant with OPR section 4.

Governance Developing and Implementing Controls

The Board also reviewed Enbridge’s governance process for developing and implementing controls to prevent, manage and mitigate the identified hazards and risks. The Board found that Enbridge’s process did not meet the Board’s requirements with respect to the design of a process. As well, the Board was unable to see evidence of clear requirements and directions for considering and applying the hierarchy of controls when developing controls.

Environmental Protection Program Hazard Identification, Risk Assessment and Control

Environmental Protection Program Hazard Identification

Within IMS-06, Environment Management System (EMS), section 3.2.1 Environmental Aspect Identification and Evaluation of Significance, Enbridge describes the process it follows to identify environmental hazards and potential hazards. This document refers to the “environmental aspect” when discussing risks and hazards. Enbridge defines “environmental aspect” as the elements of activities, products or services performed by the company that can interact with the environment. Following the identification of potential aspects, the aspects are systematically assessed to determine the level of risk and to apply control measures where required according to their established IMS and EMS processes described in this sub-section. In reviewing this process, the Board found that Enbridge has included an effective level of detail to ensure the process is implemented consistently.

Environmental Protection Program Inventory of Hazards and Potential Hazards

Enbridge provided its Liquids Pipelines business unit Environmental Protection Risk Register and a department level risk register as part of the audit documentation. At the business unit level, the risks are documented at a higher level (i.e. generalized groupings) and include risks pertaining to repeat non-compliances and improving environmental culture throughout the organization. At the department level, the risk register is detailed and the Board found that it included appropriate content with respect to Enbridge’s environmental hazards.

Environmental Protection Program Risk Evaluation

The Board identified that, at the departmental level, Enbridge has developed specific program requirements to address EMS risk management requirements. Enbridge indicated that its departmental processes are based on and linked with the Risk Management Process in IMS-01. Enbridge’s processes included analysis of information gathered in the risk identification stage to understand the nature of the risks and to evaluate any potential controls to mitigate the risks to an acceptable level. The company practices incorporated the use of a risk matrix (Heat Map) to identify and categorize risks into four groupings. At the IMS-01 level, Enbridge presented evidence that demonstrated it had set its acceptable risk tolerance as Level II (Medium Risk). According to the information provided by Enbridge, risk response plans are required to be developed for Level III and Level IV risks to reduce the risks to acceptable levels (Level II or below).

Environmental Protection Program Developing and Implementing Controls

The Board identified that Enbridge’s EMS, section 3.3.2, Environmental Risk Identification and Assessment outlined the company’s process for implementing and establishing a risk control plan. It explains the hierarchy of risk reduction controls, which ranges from administrative controls to elimination or substitution of the activity. According to this process, control plans are integrated into business unit planning, and supporting processes such as department planning and environmental emergency response training. Enbridge provided examples of environmental control plans that were in various stages of implementation and development at the time of the audit.

According to the Enbridge’s IMS-01, a control program (risk response plan) must be established for all risks assigned level II or higher. However, at the Environmental Protection Program level, IMS-06 states that a control program should be implemented for all risks assigned a risk level of III or higher. While there are program level practices that are not entirely aligned with governance processes due to the order of their documentation, the annual management system review process to improve the management systems will assist with such alignment. Additionally, records reviewed by the Board found that there were level III environmental risks in Enbridge’s Environmental Risk Registry that do not have control programs as per the IMS-06 requirements. Interviews with Enbridge staff indicated that the hazards associated with this practice were not necessarily on-going operational issues but would be categorized as project or site specific issues that are known but not covered fully by standard practices. Wildfire hazards were provided as an example. While the Board did not necessarily disagree with the practice, the Board is of the opinion that the controls development process should include clear definitions and practices to address these types of issues as failure to define the acceptable practice could lead to uncontrolled hazards.

Environmental Protection Program Communicating Controls

In reviewing Enbridge’s control development practices it was noted that the process map for risk identification and assessment states that the Environmental Protection Program is still developing its process for communicating controls. However, the Board did find evidence of controls being communicated to staff and examples included environmental bulletins, facility Environmental Management Manuals, etc. As part of their corrective action plan, Enbridge will need to establish and implement a process for communicating the controls to anyone who is exposed to the risks.

Reporting of Hazards, Potential Hazards, Incidents and Near-misses

Based on interviews and document and record reviews, the Board found that Enbridge did not have a process for internal reporting of environmental hazards at either the governance management system or program levels that met the OPR requirements. Enbridge’s tier 2 documents describe the company’s practices for identifying hazards, assessing risks and applying controls. These documents focus on the worksite and the worker. They help manage the worksite hazards and serve as appropriate administrative controls for hazard mitigation. Enbridge management and workers are required to attend formal training programs on worksite hazard identification, risk management and hazard control. During interviews and inspections at Enbridge sites, the Board noted that the programs Enbridge described in its existing tier 2 documents for hazard identification, risk assessment and controls were known and understood throughout the company’s operating regions. Updates to the program were being initiated at the time of the audit and this was understood by the employees. Regional management at Enbridge review a sample of completed forms at safety meetings and management meetings to ensure that quality is maintained.

Environmental Protection Program Data Management System

The Environment department is transitioning to a new data management system for monitoring, analyzing and trending hazards, incidents and near-misses. At the time of the audit, the company was beginning the implementation of its EnCompass system. Since EnCompass was not yet fully functional, the Environmental Protection Program was continuing to use an existing spreadsheet based practice. The company was recording and tracking information in both the old and new system during the transition. When reviewing the documents, the Board reviewed records from both systems to observe the types of incidents that were being tracked. Enbridge uses the hazard information in its data management system as feedback on the hazard and potential hazard identification process. It also uses the hazard information in its data management system to determine if additional controls are necessary for the hazards that have been identified.

Enbridge also compiles metrics, significant events and other key environmental information at the departmental and business unit level on a quarterly basis. This environmental performance reporting ensures that Enbridge tracks and reviews environmental trending data so that appropriate actions can be taken. The tracking information Enbridge reviews includes the actions taken to address trends and to support continued improvement. Enbridge’s environmental performance reporting consists of data compiled for metrics, and information on individual environmental events that require actions to be completed or need additional visibility within the organization. For example, the Pipeline Operating, Environmental Health and Safety Committee reports environmental trends and metrics.

Summary

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

The Board found that Enbridge had developed and implemented many practices for identifying, evaluating and managing its environmental hazards and risks at the program level.

The Board found Enbridge’s program level processes for evaluating risk and developing controls had deficiencies relating to the development of controls.

The Board found that at a program level Enbridge had listed the majority and most significant of its environmental; however, the process for developing a list of hazards and potential hazards within risk registers, as described in the governance management system processes, did not meet the OPR requirements.

The Board found that Enbridge had established and was maintaining a data management system for monitoring and analyzing the trends in hazards, incidents, and near-misses.

Compliance Status: Non-Compliant

2.2 Legal Requirements

Expectations:

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

References:

OPR section 6.5(1)(g), (h), (i)

Assessment:

Governance: Identifying Legal Requirements

At a governance level, Enbridge’s IMS-01, Governing Policy and Process Management System and IMS-02, Compliance and Ethics Management System describe the company’s processes for identifying and monitoring its compliance with legal requirements. The IMS-02, Compliance and Ethics Management System, section 4.5.1 indicates that the company is required to develop a master corporate compliance register and departmental compliance registers. The compliance registers link to the company’s verification processes, which are described in IMS-01, section 4.4, Health Checks and IMS-01, section 4.5, Internal Reviews. IMS-02, section 5.2, Performance Measurement and Management describes the company’s governance processes for measuring and monitoring its compliance.

The OPR requires a company to establish and implement a process to identify its legal requirements and establish and maintain a legal list of the identified requirements. IMS-02 section 4.5.1 outlines Enbridge’s processes for identifying its legal requirements and outlines requirements to develop master and departmental compliance registers. Review of this process indicated that it aligns with the OPR process requirements for identifying legal requirements and establishing and maintaining a legal list. Review of the process as documented identified that, by description it should lead to a compliant process. For example the process includes steps requiring monitoring of legal changes, updating compliance registers, etc. It also establishes roles and responsibilities. However, the Board’s audit of this process identified that it was limited to description of the requirements and did not meet the Board’s management system process requirements. Further, the process does not require the development of a single legal list. The process includes requirements to develop a master compliance register; however, this register specifically excludes certain requirements such as in orders and permits. These are to be tracked in individual departmental compliance registers.

The Board also reviewed the linked compliance verification processes that Enbridge indicated were used to monitor compliance. The Board’s review indicated that some of the processes are not designed to meet the Board’s requirements. For example, both the Health Check and Internal Review processes are specifically not expected to be comprehensive with respect to evaluating departmental or management functions or departmental or project performance. Additionally, as described in the Internal Audit sub-element 4.3 below, the Internal Review process has not been established and implemented at the time of the audit and Health Checks are limited to reviewing the existing identified requirements that have been integrated within its existing processes and practices.

Environmental Protection Program Legal Requirements

Identifying and Monitoring Compliance

The Board identified that, at the program level, Enbridge was following the EMS, section 4.8, Environment Management System Core Processes for establishing its Legal Register. This register is a subset of the larger governance-level compliance register. The Legal Register for the Environmental Protection Program identifies the primary internal and external requirements designated as significant by Enbridge based on environmental aspects, impacts and risk analysis. Enbridge staff indicated that they monitor legal requirements through various methods, such as industry associations, professional associations and legal software monitoring programs. The Board found the program level process used by the Environmental Protection Program for identifying and monitoring compliance with legal requirements has been implemented as designed.

Establishing and Maintaining a List of Legal Requirements

When reviewing Enbridge’s Environmental Protection Program legal list, the Board determined that it includes the relevant federal, provincial, and territorial legislation and regulations. This list is also used to inform the development of facility specific Environmental Management Manuals in order to ensure compliance with regulatory requirements and these Manuals were reviewed during Board inspections. However, the Board notes that Enbridge’s legal list does not include legal requirements involved in Board Certificates or Orders. For this reason, the Board found that the scope of Enbridge’s legal list does not meet the Board’s requirements.

Identifying and Resolving Non-Compliances with Legal Requirements

EMS, section 4.8 states that Enbridge maintains up-to-date and accurate compliance information in its Legal Register for its Environmental Protection Program. The company updates the Legal Register for its Environmental Protection Program to capture:

new or changed regulatory requirements;
changes in Enbridge operation and assets, such as abandonment of existing assets or implementation of new types of assets; and
changes in operating locations and jurisdictions.

The Environmental Protection Program does not specify that an MOC process must be used when legal requirements change. However, by practice Enbridge staff demonstrated that they used its MOC process for legal requirements. The Board verified this practice trough record review.

Summary

The Board found that Enbridge had developed a number of governance and program level processes and practices for identifying and monitoring its legal requirements that had accounted for the majority of its legal requirements within its environmental protection program.

The Board also found that Enbridge’s governance management system processes did not meet the OPR requirements with respect to process design and implementation.

The Board found that Enbridge had not established and maintained the legal list as required by the OPR.

Compliance Status: Non-Compliant

2.3 Goals, Objectives and Targets

Expectations:

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

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

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

References:

OPR sections 6.3, 6.5(1)(a), (b), 6.6

Assessment:

Governance: Goals, Objectives and Targets for Risks and Hazards

The OPR does not include any specific management system process requirements for developing policies and goals. However, Enbridge has established clear management system guidance with respect to its process for developing policies and goals. At a governance level, Enbridge’s IMS-01, Governance Documentation outlines the company’s expectations for documenting key corporate policies, such as the Strategic and Business Planning Processes. The Governance Documentation also explains the company’s “Planning Cascade” and associated documentation. This Planning Cascade document explains how the company links its policies and corporate vision to its performance targets and metrics. The practices described within the Governance Documentation process align with the Board’s requirements for establishing policies, goals, objectives, targets and performance measures. While not an absolute alignment between the Board’s requirements and Enbridge’s internal processes it does reflect integration of the Board’s requirements into Enbridge’s business management practices.

Environmental Protection Program Goals, Objectives and Targets for Risks and Hazards

The Environmental Protection Program uses EMS, section 3.2, Environmental Planning Processes to establish its goals, objectives and targets. This EMS section refers to section 6.1, Environmental Management Review, which outlines the annual management assessment and review of departmental metrics and data including Health Check results, Environmental Review results, investigations, audit findings, and other sources of environmental performance and system assessment data. This process aligns with the Board’s requirements for establishing goals, objectives and targets at the Environmental Protection Program level.

However, during interviews and documentation review, Enbridge indicated that its corporate goal for environmental protection would be part of the “Top Five Priorities” (Enbridge’s equivalent of corporate goals) that states “Our ability to safely, reliably, and efficiently operate and maintain our pipeline network”. This did not specifically include any environmental protection references. As the Board’s requirements towards the protection of the environment in section 6 of the OPR are explicit, Enbridge was unable to demonstrate that it had explicitly established goals that are clearly and directly related to the environment.

Summary

The Board found that Enbridge had established processes for the establishment of Goals, Objectives and Targets that align with the Board’s requirements.

The Board also found that Enbridge had not established explicit goals relating to the protection of the environment as required by the OPR.

Compliance Status: Non-Compliant

2.4 Organizational Structure, Roles and Responsibilities

Expectations:

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

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

References:

OPR sections 6.4, 20, 31

Assessment:

Governance Organizational Structure and Roles and Responsibilities

At a governance level, Enbridge demonstrated that it has a single, over-arching management system process that describes the organizational structure and responsibilities for the ongoing development and implementation of its management system. The IMS documents defined the roles and responsibilities regarding occupational health and safety of all employees and contractors.

The governance management system documents indicated that Enbridge’s executive management was responsible for upholding the management system policies, process, standards and requirements. They were also responsible for ensuring that appropriate resources are available to monitor compliance and implement continuous improvement of the management system. Further the documentation identified that Enbridge’s President’s responsibilities include allocating the resources necessary for management system compliance.

Governance Annual Evaluation of Resource Need

Enbridge demonstrated that it has developed a number of corporately required or supported mechanisms for evaluating its resourcing needs.

Enbridge did not; however, provide specific documentation and records to demonstrate it evaluates the need for human resources allocated to establishing, implementing and maintaining its management system and explicitly meeting its OPR section 6 obligations at a corporate or program level.

Environmental Protection Program Organizational Structure and Roles and Responsibilities

Roles and Responsibilities

During the audit, Enbridge indicated that the Vice President of Health, Safety, Environment and Support Services is the management system owner of the company’s Environmental Protection Program. Enbridge provided documents and records that demonstrated it had established and maintained documented roles and responsibilities statements related to its environmental protection program and activities that applied to all levels within the organization as well as contractors. Through document and record review and staff interviews the Board identified that Enbridge had established, documented and communicated its organizational structure as it related to environmental protection.

Annual Evaluation of Resource Need

Enbridge demonstrated that it uses several mechanisms to evaluate its human resources needs. Key examples include:

Liquids Pipelines priorities and objectives review and planning - The leadership team defines the key priorities and objectives for Liquids Pipelines in alignment with the Strategic Plan; the Strategic Plan defines the focus and priorities for the company as a whole;
Environment Department Plan development - IMS-01 processes outline the steps involved in developing a Department Plan and resourcing the department;.
Workforce planning - The Enbridge Human Resources department leads the Environmental department through the Workforce Budgeting process. As a result of this process, the department identifies the job types and the number of each job type required to ensure there are sufficient resources to meet management and protection requirements.
Annual Work Plan update and development - The Environmental department develops a detailed annual work plan that takes into account the priorities, objectives and Department Plan of the Liquids Pipelines business unit. This includes an evaluation of the resources required for the Environmental department.

The Board identified that the resource evaluation mechanisms described were being implemented within the environment department. In reviewing the documentation and records associated with resource evaluation mechanisms, the Board identified that Enbridge’s practices were not accounting for staff outside of the department with environmental protection responsibilities. For example Field Operations and Maintenance staff have environmental protection management responsibilities that require accounting for. Additionally, Enbridge did not provide specific documentation to demonstrate it evaluates the need for human resources allocated to establishing, implementing and maintaining its management system and meeting its obligations as described in the OPR.

Summary

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.

The Board found that Enbridge had established and implemented several mechanisms for reviewing its environmental protection program workforce needs.

The Board also found that Enbridge’s evaluation of need did not specifically account for all staff with management system establishment, implementation or maintenance or environmental protection responsibilities and, therefore, did not demonstrate that the human resources allocated to establishing, implementing and maintaining its management system and meeting for meeting its OPR section 6 obligations are sufficient.

Compliance Status: Non-Compliant

3.0 IMPLEMENTATION

3.1 Operational Control-Normal Operations

Expectations:

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

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

References:

OPR section 6.5(1)(e), (f), (q)

Assessment:

Governance Developing and Implementing Operational Controls - Normal Operations

At a governance level, Enbridge’s IMS-01, section 4.3, Risk Management Process describes the company’s process for developing and implementing controls for addressing its hazards and risks. As noted in sub-element 2.1 of this audit, the Board found that this Enbridge process is non-compliant for several reasons, including the process design and implementation of the hierarchy of controls. Since the Board has already identified that Enbridge will have to develop corrective action plans for sub-element 2.1, the Board will not assign additional non-compliances for the governance process in this sub-element; however, Enbridge must specifically consider and include any corrective actions associated with this sub-element within the corrective action developed plan developed for sub-element 2.1.

Governance Processes for Coordinating, Controlling and Managing the Operational Activities of Employees and other People Working With or On Behalf of the Company

These management system process requirements are described in OPR section 6.5 (1) (k) and (q). During the audit Enbridge indicated that these requirements were described within its IMS-01 sections 2.4 Management System Development and Implementation Requirements and 4.14 Workforce Competency and Qualification Management Process and in its OMMs and various other program level processes.

Review of the IMS processes indicated that they did not address the requirements identified in the sub-element directly and that, as noted elsewhere in this report the IMS-01 4.14 Workforce Competency and Qualification Management Process has not been demonstrated to be established or implemented. Review of the OMM processes indicated that they were not considered as governance management system process within the company. Enbridge is therefore non-compliant with respect to its OPR management system process requirements.

Environmental Protection Program Developing and Implementing Operational Controls - Normal Operations

As noted in sub-element 2.1 above, The Board identified that Enbridge’s EMS, section 3.3.2, Environmental Risk Identification and Assessment outlined the company’s process for implementing and establishing a risk control plan. It explains the hierarchy of risk reduction controls, which ranges from administrative controls to elimination or substitution of the activity. According to this process, control plans are integrated into business unit planning, and supporting processes such as department planning and environmental emergency response training. Enbridge provided examples of environmental control plans that were in various stages of implementation and development at the time of the audit.

The Environmental Protection program created Environmental Management Manuals for each facility in 2012. These manuals give site Operations personnel a single reference for procedures for all relevant environmental requirements at each facility. Enbridge uses these manuals to describe its process for tracking permit requirements to the municipal level as applicable for each facility. Based on interviews and document review, the Board found that staff in the Environmental Protection program provides training related to the Environmental Management Manuals, particularly if a significant activity or process in these manuals changes.

Based on the document and record review and subject to its finding for sub-element 2.1 above, the Board found that Enbridge had developed and implemented a significant number of programs, processes and practices to prevent manage and mitigate it environmental hazards.

Environmental Protection Program Coordinating, Controlling and Managing Operational Activities

During interviews, Environmental Protection program staff indicated that they use the same methods for controlling and coordinating the operational activities of employees and other people working on behalf of the company, as they do for communicating control programs. Enbridge described several activities and practices that the company uses to coordinate the activities of contractors and consultants. The Board found that Enbridge used a number of practices such as pre-job hazard assessments, project risk assessments and tailgate meetings to coordinate Enbridge staff and contractors to ensure that activities are completed in a way that is safe and protects the environment. While the Board saw evidence of the practices described, Enbridge did not demonstrate that it had had a documented process for coordinating the activities of contractors and consultants at the environmental protection program level.

Summary

The Board found that, subject to its findings in sub-element 2.1 above, Enbridge had a process for developing controls to prevent, manage and mitigate its identified environmental hazards.

The Board found that Enbridge had developed controls to prevent manage and mitigate its identified environmental hazards.

The Board found that Enbridge had established processes and practices for coordinating, controlling and managing its operational activities within its environmental protection program.

The Board also found that Enbridge did not demonstrate that it had established and implemented a documented process for coordinating the activities of contractors and consultants at the environmental protection program level.

Compliance Status: Non-Compliant

3.2 Operational Control-Upset or Abnormal Operating Conditions

Expectations:

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

References:

OPR section 6.5(1)(c), (d), (e), (f), (t)

Assessment:

Governance Upset and Abnormal Operating Conditions

Enbridge uses the processes described in sub-elements 2.1 and 3.1 of this audit report to identify hazards and potential hazards to the occupational health and safety of its workers during abnormal operating conditions, accidental releases, incidents and emergency situations. Therefore, the general findings of those sub-elements apply to this sub-element as well. Since any issues applicable to this sub-element must be addressed in the corrective action plan developed for sub-element 2.1, the Board will not assign further Non-Compliances for the governance process in this sub-element.

Governance Developing Contingency Plans for Abnormal Events

The Board requires the company to establish and implement an effective process for developing contingency plans for abnormal events that may occur during construction, operation, maintenance, abandonment or emergency situations. It is important to note that contingency plans are not limited to emergency response. The Board found that Enbridge’s governance processes did not include specific processes or policies for developing contingency plans for abnormal events.

Environmental Protection Program Upset or Abnormal Operating Conditions

The Board found that Enbridge’s EMS, section 3.1, contains a process for developing and implementing controls to prevent, manage, and mitigate environmental hazards and risks, including those associated with abnormal or upset conditions. The process requires Enbridge to use a hierarchy of risk reduction controls when developing the risk control plans. One of the control programs being implemented by the Environmental Protection department is related to environmental emergency response. This was the same process applied for normal operating conditions.

Review of the information provided by Enbridge identified that within it had developed the Enbridge Environment Emergency Response Directory as a reference guide for environment staff to access critical environmental emergency response information and resources in the event of an environmentally related incident. The directory contains information on emergency response procedures and expectations, resources, templates, suppliers and contractors, and monitoring plans for air, water, wildlife and waste management. The Board reviewed documentation and records that indicated that Enbridge reviews and updates the directory once a year. The directory outlines the tasks expected of environmental staff such as air monitoring planning, wildlife deterrence planning and site sensitivity analysis, among others. As well, Enbridge demonstrated that its environmental protection staff is responsible for developing environmental sensitivity maps for all of the pipeline corridors. These maps are shared with the Emergency and Security department for application during planning and incident response.

Environmental Protection Program Developing Contingency Plans

During the audit, Enbridge environmental staff indicated that they do not have an established and implemented program level process for developing contingency plans for abnormal events that may occur during construction, operation, maintenance and abandonment activities. Regardless of the lack of process, Enbridge was able to demonstrate that it was developing contingency plans as a matter of practice where a need was identified. Enbridge provided documentation to demonstrate the development of contingency plans. Examples reviewed by the Board included the contingency plans and procedures within the Enbridge Safety and Environmental Construction Manuals and Waste and Vegetation Management Plans.

Summary

The Board found that, subject to its non-compliant finding relating to its governance management system process with respect to developing controls (Sub-element 2.1 Hazard Identification, Risk Assessment and Control, above), Enbridge has developed controls that address its identified environmental protection hazards and risks relating to upset and abnormal operating conditions.

The Board found that Enbridge has developed and documented contingency plans as a matter of practice.

The Board also found that Enbridge had not established a management system or program level process for developing contingency plans that meets the Board’s requirements.

Compliance Status: Non-Compliant

3.3 Management of Change

Expectations:

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

References:

OPR section 6.5(1)(i)

Assessment:

Governance Management of Change Process

During the audit, Enbridge identified that it had developed a governance management of change process. In reviewing the documents and records and conducting interviews, the Board found that Enbridge’s governance process had not been fully established or implemented at the time of the Board’s audit. The Board’s review found that Enbridge’s design of its governance process does not meet the OPR management system process requirements.

During the audit, Enbridge indicated that MOC processes and requirements are embedded in all of its existing written processes, procedures and practices. Enbridge indicated that a single MOC process would not be able to meet its or other companies with significant facilities and processes, requirements. Therefore, Enbridge has multiple processes embedded in multiple locations. Further, Enbridge indicated that its interpretation of the OPR is to “ensure that a MOC process is available for unplanned, unexpected or infrequent changes that are not already embedded in existing activities and processes. There is no requirement in the OPR for these various management of change processes to be formally tied to one another.”

The Board has found that Enbridge’s interpretation and practices are inconsistent with the Board’s interpretation of the OPR process requirements. The Board notes that the OPR requires a company to develop a management system MOC process that identifies and manages any change that could affect safety, security or the protection of environment, not only those described by Enbridge. Further the Board notes that, while a company may have multiple processes, there still must be consistency in process requirements, development and implementation as well as coordination of the various practices in order to meet the OPR requirements and to ensure formal management. The Board notes that a singular management system process developed to meet the OPR requirements, as prescribed, would address these requirements.

Environmental Protection Program Management of Change

Notwithstanding, the process issues described above, the Board found that Enbridge had established and embedded MOC requirements within many aspects of its Environmental Protection program. The documented, operational MOC processes are found in Enbridge’s OMMs. Enbridge uses two core MOC processes to manage OMM changes:

Liquid Pipelines MOC process - This process identifies and manages any change critical to the safety management and operational reliability of the Enbridge system; and
Operations and Maintenance Procedures Management System - This system includes various processes to ensure proper MOC of its core procedures.

In reviewing Enbridge’s processes and practices, the Board identified that the company has incorporated formal communication requirements into its practices. The company divides its communication of changes into two categories: annual updates and critical updates. The company has formal written requirements for both of these categories. Further, Enbridge demonstrated that it uses an online database to validate, communicate and follow-up on MOC activities. The system is available to all employees and all employees demonstrated familiarity with the system during Board interviews. Interviews with Enbridge regional personnel confirmed that they have an appropriate understanding of the company’s MOC system and the communication practices.

Summary

The Board found that Enbridge demonstrated that it had established and implemented a number of MOC procedures and practices to document and manage change at the program level on a consistent basis. The Board identified that all departments and programs were using Enbridge’s Liquids Pipelines MOC process, including environmental protection, as its primary corporate MOC process. The Board, however, identified that this process did not meet all of the MOC process requirements and was specifically not intended to be included within its IMS process.

The Board also found that Enbridge was did not demonstrate that it had established and implemented a management system level process that meets the requirements of the OPR.

Compliance Status: Non-Compliant

3.4 Training, Competence and Evaluation

Expectations:

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

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

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

References:

OPR section 6.5(1) (j), (k), (l), (p)

Assessment:

Governance and Environmental Protection Program Competency Processes and Training Program

Through interviews and document and record review, the Board found that Enbridge has established and implemented a documented, comprehensive training program applicable to occupational health and safety training of its employees. The training program is appropriately supported and managed throughout the organization. Enbridge has developed a management system called the Enbridge Learning Management System (eLMS). eLMS provides the mechanism to register, deliver, track and record learning completions. Enbridge’s Human Resources department provides support to all departments for the development of departmental content and eLearning programs and each department manages the content of programs housed in eLMS. The Board verified that Enbridge has implemented the systems to generate, manage and document the various training programs through front line interviews and inspections.

Notwithstanding Enbridge’s training program implementation, the Board found that Enbridge had not established and implemented documented processes for developing competency that are used to develop training and learning programs and to establish baseline competencies required for employees and others working on behalf of the company to perform assigned tasks in a manner that is that is safe, ensures the security of the pipeline and protects the environment. Similarly, the Board found that Enbridge has not established and implemented a process for verifying competency as required. Interviews with staff indicated that there were undocumented competency evaluation processes being undertaken at the time of the audit; however, they did not meet the Board’s management system process requirements. Record reviews conducted by the Board indicated that Enbridge had at one time implemented a formal Competency Based Training program but that had been officially discontinued a number of years ago. It was identified that staff in some of the regions were still implementing the practices of this program as a method to ensure competency of new staff.

The Board considers competency identification and verification to be a key component in assuring the safety of workers, the public, and the environment. Therefore, this issue was brought to Enbridge’s attention as requiring urgent attention. . Enbridge has responded by developing an interim process while Enbridge’s Workforce Competency and Qualification Process (WCQP), commenced in 2013, is being fully rolled out. This was provided to the Board for review prior to end of its close-out discussions. While not yet demonstrated as established or implemented, based on initial interviews with departmental staff, the Board found that the described practices could meet the Board’s requirements.

The Board’s review of the written governance policy that had been provided by Enbridge indicated that some of the key legally required process requirements were mapped as “red”. According to Enbridge’s described process mapping convention this would indicate that the process steps are “aspirational” and therefore outside of its legal requirements to be measured by the Board. As noted elsewhere in this report, aspirational or stretch practices are encouraged but they cannot include legally required content within this category.

Generating and Managing Training Documents and Records

The Board found that Enbridge’s process for generating and managing training documents and records is largely based on the following:

Enbridge Learning Management System - to manage department training records;
Matrix Verification Reports on the Field Operations Learning Management System (TRAC);
Individual Development Plans - to manage training and records at an individual level; and

In reviewing the records, Enbridge demonstrated that it had an established, implemented and effective process for generating training documents and records.

Summary

The Board has found that Enbridge has established and implemented formal management system for identifying and managing its training requirements.

The Board also found that Enbridge has not established and implemented processes for identifying and verifying the competency requirements of its workers as required in the OPR. The Board identified that Enbridge has started to implement a new process for the identification and verification of worker competency. However, this new process remains Non-Compliant as it has not been established or implemented and that its governance management system process does not meet the Board’s requirements

Compliance Status: Non-Compliant

3.5 Communication

Expectations:

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

References:

OPR section 6.5(1)(m)

Assessment:

Governance Communication Process

The Board found that Enbridge’s governance level management system processes are inadequate. Enbridge’s IMS-01 is limited to requiring that each department must develop a communication plan and does not meet the OPR requirements.

Environmental Protection Program Internal and External Communication Process

The Board found that Enbridge has undertaken a lot of communications both externally and internally. As well, Enbridge has integrated communications requirements within many of its processes and procedures.

During the audit, the Board identified that Enbridge’s EMS, section 4.5, Communication and Participation described the communication process requirements for the Environmental Protection Program. This process focuses on internal communication and requires the developed of an Environmental Communication Plan. During interviews, Enbridge staff confirmed that the required communication plan had not been developed but through record reviews, Enbridge was able to demonstrate how it communicates messages about the environment through numerous activities, such as quarterly reports, alerts, and presentations to staff.

Review of the EMS communication process indicated that it had included external communication requirements but it is limited to communicating with regulators as all other external communication activities are handled through company approved spokespeople. The Board has no concerns with this approach.

Summary

The Board found that Enbridge communicates throughout its organization as a matter of organized practice.

The Board also found that Enbridge had not established or implemented a communication process that meets the Board’s requirements.

The Board also found that Enbridge has not developed a communications plan as required by its processes. The Board notes that this is a requirement of CSA Z662-11, an OPR referenced standard.

Compliance Status: Non-Compliant

3.6 Documentation and Document Control

Expectations:

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

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

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

References:

OPR sections 6.5(1)(i), (n), (o), 6.5(3)

Assessment:

Governance Process for Identifying the Documents Required to Meet its Obligations

This sub-element also includes the requirements to develop a process for identifying the documents required for the company to meet its obligations described in OPR section 6.

In the information provided to the Board, Enbridge indicated that its interpretation of the OPR requirements is that the required documents to meet its obligation are “those documents developed as part of the management system required by the OPR”. Enbridge further identified that its management system design is comprehensive and encompasses the all of the company’s activities that are designed to meet the obligations. As such it indicated that its IMS - 01 section 1.3 Integrated Management Structure identifies the documents required. The Board’s review of this section indicated that it did not constitute a list of documents or classes/categories of required documents. It was a high level description of the nineteen management systems that comprise Enbridge’s management system and high level descriptions of the content of each.

Governance Documentation and Document Control

During the audit, Enbridge was not able to demonstrate that it had established or implemented a governance management system process that meets the Board’s documentation and document control process requirements. Enbridge did not provide a documented management system process until after the Board’s closeout discussions. This document was dated 22 August 2014; however, until provided by Enbridge, the Board was not presented evidence of its existence either as a document or as referred to by Enbridge staff during interviews. The Board could not therefore verify its establishment or implementation during the audit.

The Board’s review of this document indicated that it did not meet the OPR management system process requirements as described elsewhere in this audit report. As well the Board could not determine the applicability of the process to the programs required in OPR section 55 as the process as written only applies to the governance management system processes.

Regardless of the Enbridge’s lack of compliant management system processes, the Board found that Enbridge does have some document control processes that it is presently using on a corporate basis. Enbridge governs its document processes through its Documents Policy, which is available on the company’s intranet and through an online tool called the Governance Documents Library. The Board identified that the Documents Policy and its associated practices and tools set Enbridge’s minimum standards for documents and document tracking.

Environmental Protection Program Documentation and Document Control

As stated in EMS, section 4.9 Enbridge uses a standardized and consistent process for recording and tracking environmental information. The Environmental Protection program controls its document by:

complying with all regulatory documentation requirements, systems and procedures;
using revision codes, release dates, file creation information and other appropriate means to control document revisions; and
using a process similar to the OMM MOC process for changes to its Environmental Management Manuals.

Based on document and record review, the Board has found that the document control practices applied to Enbridge’s Environmental Protection Program is meeting the expectations of the OPR compliant with this sub-element.

Summary

The Board found that Enbridge had established and implemented processes and practices for controlling its environmental protection program documentation at a program level.

The Board also found that Enbridge had not established and implemented a governance management system process for identifying the documents required for the company to meet its obligations under OPR section 6.

The Board also found that, at the governance level, Enbridge’s new IMS-01, section 4.9 Governance Document Control Process, dated 22 August 2014, did not meet the OPR requirements nor had it been established and implemented.

Compliance Status: Non-Compliant

4.0 CHECKING AND CORRECTIVE ACTION

4.1 Inspection, Measurement and Monitoring

Expectations:

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

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

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

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

References:

OPR sections 6.1(d), 6.5(1)(g), (s), (u), (v), (w), 56

Assessment:

Governance Inspection, Measurement and Monitoring

The Board requires companies to have an established, implemented and effective process for inspecting and monitoring the company’s activities and facilities to evaluate the adequacy and effectiveness of the protection programs and for taking corrective and preventive actions if deficiencies are identified.

Through staff interviews, and document and record review, the Board found that Enbridge has documented its governance management system inspection, measurement and monitoring practices in its IMS-01 manuals. The IMS documents describe Enbridge’s process for Health Checks, internal reviews, audits and external audits. The Board completed a full review of the Health Checks, internal reviews, audits and external audits as part of its evaluation of Enbridge’s Internal Audits and Quality Assurance Program and has documented them in Sub-element 4.3 Internal Audits, below. The Board has identified deficiencies with the processes and practices that directly relate this sub-element as well. The Board, however, will not assign an additional non-compliance based on that finding within the section. Enbridge’s CAP must include corrective actions that ensure that the processes will address the linked requirements within this sub-element explicitly.

Surveillance and Monitoring Program

The OPR requires companies to develop and implement surveillance and monitoring program. During its audit the Board identified that Enbridge undertakes numerous types and a high number of monitoring and surveillance activities of its regulated facilities. The Board found, however, that the amalgamation of activities do not meet the OPR section 39 program requirements with respect to design and management. The Board has included its program requirements with Section 1.0 Audit Terminology and Definitions in the attached audit report.

Governance Corrective and Preventive Actions

During the audit, Enbridge indicated that its IMS, section 4.6, Corrective and Preventive Action Management Process defines the minimum standards for administering, tracking and managing corrective and preventive actions through their implementation and resolution. This process applies to Enbridge departments and addresses events, hazards and near-misses. This process includes Health Checks, internal reviews, regulatory inspections, investigation and audits. The documentation provided at the time of the audit does not show that Enbridge’s Corrective and Preventive Action Management Process has been fully implemented. Portions of the process, according to the process map, have only been partially implemented at the IMS level.

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.

Environmental Protection Program Inspection, Measurement and Monitoring

Inspection, Measurement and Monitoring

At the Environmental Protection program level, Enbridge uses several processes and activities during the inspection of its facilities. This includes:

Health Checks;
OMM Inspections;
Aerial overflights; and
Environmental Reviews (to be discussed in sub-element 4.3);

Enbridge’s process requirement states that a Health Check is to be completed on one facility per region per year. However, during interviews Enbridge staff indicated that the company’s Regional Analysts must complete two facility Health Checks per region per year, and this requirement is included in their annual individual performance agreements. Records reviewed by the Board confirmed that these Health Checks have occurred as described. In reviewing Enbridge’s inspection practices, the Board notes that, in larger regions such as Enbridge’s Central Region where there are ten facilities, this inspection frequency could result in Enbridge conducting Health Checks and Environmental Reviews once every five years at individual sites. In the Board’s opinion, this frequency is not sufficient to actively monitor the environmental health of Enbridge’s facilities.

It was also noted by the Board that Fields Operations staff also conduct standardized facility inspections that include environmental considerations (in addition to safety and security aspects). Review of Enbridge’s standard field inspection form indicated that it contains specific environmental items that should be assessed, including appropriate waste storage, vegetation management, secondary containment and soil erosion. The Board reviewed records of these inspections during its audit and noted the following issues:

only one record was properly completed (Enbridge could therefore not demonstrate that environmental aspects were being appropriately assessed through this activity); and
the scope of these inspections specifically does not include the entirety of sites subject to the inspection, for example the inspections exclude laydown and storage areas.

During the audit, Board staff conducted several environmental inspections of Enbridge’s terminals and noted environmental non-compliances such as waste storage and vegetation management issues within in these excluded areas. The Board is of the opinion that had the Enbridge’s field facility inspections included these areas, these non-compliances would have been prevented.

ROW Aerial Inspections

Enbridge stated that it relies almost exclusively on its aerial inspections for surveillance and monitoring of its pipeline ROWs. Enbridge patrols its pipeline system on a regular basis using fixed wing aircraft and helicopters. With the exception of ROW aerial inspections of Enbridge’s gathering system in Saskatchewan, all pilots completing the ROW aerial inspections are Enbridge employees. Enbridge Pipeline Saskatchewan Inc. contracts its ROW inspections to a company in Saskatchewan that patrols the gathering system on behalf of Enbridge. The Board found that Enbridge’s ROW patrol frequencies are in compliance with the intent of the CSA Z662-11 standard and regulation for pipeline patrol frequency.

The Board reviewed Enbridge’s procedures and reports for aerial ROW patrols. When reviewing records associated with this activity, environmental conditions of the pipeline right-of-way were only reported by exception or issue only. Therefore, Enbridge could not demonstrate that environmental aspects were being appropriately assessed through this activity.

Monitoring and Inspecting Compliance with Legal Requirements

As discussed in Section 2.2 of this audit report, Enbridge had a process for identifying the legal requirements of its Environmental Protection program and has established an environmental legal list. However, the legal list did not include NEB conditions. The Board is of the opinion that correcting the deficiency in Section 2.2 will ensure that Section 4.1 is also compliant with this requirement.

During the Audit Enbridge indicated that it uses a number of different practices for verifying its compliance including Health Checks and Internal Reviews. During review of these processes and their application within the environmental protection program the Board noted the following practices and deficiencies. Health Checks do not directly assess if the environmental legal list is being followed. Health Checks review the implementation of management plans, such as the Vegetation and Waste Management Plans and the OMMs and the company’s procedures. If these documents have been updated as the result of changes to legal requirements, then Health Checks are intended to ensure the updated documents are being implemented to meet the changes in legal requirements. In interviews, Enbridge staff indicated that the protocols for Environmental Reviews, which by process include a review of the legal requirements, are developed for each individual review by the third-party auditor brought in to lead the review. By structuring the protocol this way, Enbridge ensures that the legal requirements are updated yearly at its program level.

Based on its assessment of the Health Check and Environmental Review processes, the Board found that Enbridge is monitoring most of its compliance requirements on a regular basis; however, Enbridge did not demonstrate that it was accounting for all of the legal requirements identified in OPR section 53.

Summary

The Board found that, subject to its findings related to its review of Enbridge’s Health Check and Internal Review processes (Sub-element 4.3 Internal Audit), Enbridge has established and implemented processes for inspecting, measuring and monitoring its facilities and program.

The Board also found that Enbridge’s inspection processes and practices do not meet the Board’s requirements.

The Board also found that Enbridge had not developed surveillance and monitoring program that meets the requirement of OPR section 39.

Compliance Status: Non-Compliant

4.2 Investigating and Reporting Incidents and Near-misses

Expectations:

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

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

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

References:

OPR sections 6.5(1)(r), (s), (u), (w), (x), 52

Assessment:

Governance Investigating and Reporting Incidents and Near-misses

The Board notes that there is not a specific OPR management system or other process development requirement for investigating incidents or near-misses. The Board, however, considers processes for conducting investigations to be implicit with any process developed to satisfy OPR 6.5(1) (r) and therefore companies must demonstrate how they develop adequate and effective corrective and preventive actions associated with incidents and near-misses.

Enbridge provided its IMS-01 4.10 Event Investigation Processes, and its IMS-01 4.6 Corrective and Preventive Action Management (CAPA) Process in support of it meeting the requirements of OPR 6.5(1)(r). The Board found that Enbridge’s Event investigation Processes were designed in aid of understanding the causes of events from the perspective of root and contributory causes to prevent recurrence within the Enbridge entities to which it is applied. The processes included Event Investigation Principles, Event Impact Criteria and Low and Medium and High Impact Event Investigation Processes. The IMS-01 4.10 processes were documented in detail. Review of the associated process maps indicated that the processes included specific links to the IMS-01, 4.6 CAPA process for assurance of consistent corrective and preventive action development and implementation. Review of the IMS- 01, 4.6 CAPA Process is documented below.

The Board noted that the process maps provided to the Board indicated that the processes had not been full established and implemented at the time of the Board’s audit. Regardless of the full implementation of the processes, the Board was able to see evidence of implementation of key investigation process activities within Enbridge’s program level activities in its audit activities.

Governance Corrective and Preventive Actions

During the audit, Enbridge indicated that its IMS, section 4.6, Corrective and Preventive Action Management Process defines the minimum standards for administering, tracking and managing corrective and preventive actions through their implementation and resolution. This process applies to Enbridge departments and addresses events, hazards and near-misses. This process includes Health Checks, internal reviews, regulatory inspections, investigation and audits. The documentation provided at the time of the audit does not show that Enbridge’s Corrective and Preventive Action Management Process has been fully implemented. Portions of the process, according to the process map, have only been partially implemented at the IMS level.

Environmental Protection Program Investigating and Reporting Incidents and Near-misses

Incident Reporting

During interviews, Enbridge staff referred to OMM, Book 1, General Compliance Reference, 02-02-01, Incident Reporting. Table 6 in this document is specifically about the environment and is entitled Adverse Environmental Effects of Environment Non-Compliance. This table defines an adverse environmental effect as a situation or activity that can adversely effect on the environment. The table provides additional details for Enbridge staff on the reporting requirements and deadlines involved.

Enbridge’s OMMs also document the company’s incident investigation process. The OMMs describe the criteria for what is investigated and why, as well as stakeholder responsibilities, the investigation process, training requirements for investigators, and documentation requirements.

Corrective and Preventive Actions

At a program level, EMS, section 5.3, Non-Compliance, Corrective, and Preventive Action and section 5.4, Escalation of Events explain Enbridge’s Environmental Program processes for investigations, non-compliances and corrective and preventive actions. The Board reviewed these documents during its audit and identified the following information. The Non-Compliance, Corrective, and Preventive Action document provides the tools for systematically identifying, prioritizing and closing environmental issues and actions. It also describes the procedures for reporting all environmental non-compliance issues so they can be analyzed and assessed to promote and drive ongoing improvement. The Escalation of Events section establishes procedures for escalating types of incidents and events to ensure that all material events, incidents, actions or conditions (whether actual or perceived) are reported and properly evaluated. This document section further details the process Enbridge follows when investigating an environmental incident. The Escalation of Events section includes a sub-section on Learning and Deployment. After Enbridge completes an incident investigation, the significant lessons learned from that incident must be shared to make other systems more robust and to minimize the chance for reoccurrence. The Board notes that, because the EMS was published and implemented before the IMS was released, Enbridge will have to align the departmental management system sections with the IMS, or vice versa, once the IMS has been implemented to be compliant.

With respect to investigating instances of identified non-compliance, the Board identified that the Environment department did have processes in place for investigating non-compliances. These processes are documented in OMM, Book 1, Incident Reporting, which includes reporting hazards, potential hazards and near-misses. In reviewing the documents, the Board found that the process map for the Corrective Action process indicated that the process had only been partially implemented at the time of the audit. The Board is of the opinion that this may be due to the alignment concern between the EMS and IMS that the Board identified previously.

The Board reviewed two examples of environmental incident investigations completed by Enbridge. The results of these investigations led to recommendations for updating the company’s training, environmental manuals and changes in the sign-off procedures for its Environmental Protection Plans that are completed before projects are kicked off.

Summary

The Board found that Enbridge has developed processes for reporting on hazards, potential hazards, incidents and near-misses, and for taking corrective and preventive actions.

The Board found that Enbridge has conducted investigations where required or where hazards, potential hazards, incidents and near-misses have or could have resulted in the safety the public, company employees and the pipeline being significantly compromised.

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.

The Board also found that Enbridge’s process for taking corrective and preventive actions is not being implemented as required by OPR. The Board has documented this deficiency in sub-element 4.3 Internal Audits, below. Enbridge is required to specifically consider and include corrective actions to address the process deficiencies identified in this sub-element within and corrective action plan developed for sub-element 4.3.

Compliance Status: Non-Compliant

4.3 Internal Audits

Expectations:

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

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

References:

OPR section 6.5(1)(w), (x)

Assessment:

Governance Quality Assurance Program

During the Board’s audit, Enbridge indicated that quality assurance is implicit within a management system, especially within the “Check-Act” elements of the standard “Plan-Do-Check-Act” structure to which it follows. Therefore, Enbridge’s indicated that it met the Board’s requirements to establish and implement a documented Quality Assurance Program by having a documented, appropriately designed management system that incorporates quality assurance activities.

In reviewing Enbridge’s “Check-Act” elements, the Board noted that they do contain a number of activities that would normally be considered quality assurance activities. Examples of these activities are inspections, audits, data trending, monitoring performance measures, etc. Within the limitations of the results of the Board’s audit associated with the elements, the Board was able to view records of the activities being implemented as required.

The Board has found, however, that Enbridge’s interpretation of Quality Assurance Program is incorrect. The Board has found that Enbridge has not met its expectations with respect to “programs”. The Board has provided clear guidance as part of the guidance notes that accompany the OPR that a program is not simply a description of activities. Programs are:” a documented set of processes and procedures designed to regularly accomplish a result. A program outlines how plans, processes and procedures are linked, and how each one contributes toward the result. Program planning and evaluation are conducted regularly to check that the program is achieving intended results”. The Board’s definition is included in Section 1.0 Audit Terminology and Definitions of the attached audit report.

Governance Internal Audits

Enbridge indicated that its management system includes processes that meet the Board’s auditing process requirements. Enbridge indicated that it accounts for the OPR requirements using a combination of its Health Check and Internal Review processes. While not standard in its approach to conducting audits, the Board reviewed Enbridge’s practice to determine whether it met the OPR requirements. Additionally, Enbridge indicated that the Board should consider the audits completed as part of its Internal Auditing program activities as part of its demonstration of undertaking the required audits.

The Board found through its review of documentation and records associated with the two referenced processes that they did not individually or together constitute a compliant auditing process. The Board found that both processes were specifically designed not to be exhaustive in their reviews of practice, processes or legal requirements. Further, the Internal Review process had not been fully established or implemented at the time of the audit. Enbridge was in the process of confirming the design of the process by conducting a review of one of its internal processes.

As noted, Enbridge provided a description of its Internal Auditing process and activities as well as selected records of completed audits as a demonstration of completing audits. Review of the Internal Audit process indicated that it was a process designed to be implemented based on corporate risk priorities as directed by Enbridge’s senior governance and not a repeatable compliance review process applicable directly to the Board’s requirements. Additionally, the audit records did not demonstrate it had conducted audits compliant with OPR sections 53 or 55.

Additionally, Enbridge indicated that it had conducted a number of internal and 3rd party assessments of its management system against its OPR requirements. Review of the associated records provided by Enbridge indicated that they were evaluations of the alignment of Enbridge’s management systems with the OPR management system and program requirements and did not evaluate the adequacy and effectiveness or compliance of the company practices.

Based on the Board’s review of Enbridge’s audit processes, audit activities completed to date and other linked processes such as those related to legal requirements, Enbridge was unable to demonstrate that it had completed audits consistent with section 53 of OPR. Further, the Board finds Enbridge’s integrated management system process for conducting audits does not meet the Board’s requirements from the perspective of present design and of Enbridge’s interpretation of audits.

As noted above, Enbridge’s Health Check and Internal Review processes have specific design issues that, when evaluated together, do not meet the Board’s audit expectations with respect to comprehensiveness of the required audits. Additionally, the Board finds that Enbridge’s interpretation that the OPR audit requirements can be met using a combination of processes conducted over a number years is incorrect. The Board notes that there is a common understanding that an audit is a discrete verification activity that allows for an assessment of conformance/compliance to be made at a given time. The Board notes that the comprehensive audits it requires necessitates evaluation of systems and programs that require evaluation of linked processes and evaluations of the adequacy and implementation of the system, programs and processes. This requires specific coordination of the reviews in terms of time, processes, programs and regions. Enbridge’s present practices, based on its interpretation of the regulations, do not allow for the required assessments to be made. The Board understands that audits often contain a number of different activities; however, each activity is coordinated within the auditing process and scheduled within the individual plan for the audit.

Auditor Training

This sub-element indicates that a company audit process should identify and manage the training and competency requirements for staff carrying out the audits. Enbridge did not demonstrate that its training and competency activities account for staff implementing its audit related processes. The Corrective Action Plan associated with the Board’s Non-Compliant finding related to Training and Competency and Evaluation as described in sub-element 3.4 above will need to explicitly address this issue.

Governance Corrective and Preventive Actions Process

The Board’s audit process requirements include establishment and implementation of a process for taking corrective and preventive actions to address any deficiencies identified by the audits. As part of its review of the documentation and records provided by Enbridge, the Board reviewed the establishment and implementation Enbridge’s corrective and preventive action process. The Board found that Enbridge had developed a Corrective and Preventive Action (CAPA) Management Process and included it within its IMS governance documentation (IMS-01, section 4.6 Corrective and Preventive Action Management Process). Review of this governance process indicated that it did not meet the Board’s process design requirements as outlined in Section 1.0 Audit Terminology and Definitions section of the attached audit report. For example there are no definitions of corrective or preventive actions or appropriate linkages to or from other management system processes. Additionally, the process map indicated that none of the required steps were fully implemented.

Environmental Protection Program Quality Assurance Program and Internal Audits.

Quality Assurance Program

As noted above, Enbridge was unable to demonstrate that it has an established, implemented and effective quality assurance program for its management system and Environmental Protection Program; however, the company did provide examples of completed audit and review activities and did provide an overview of several inspection programs which are being completed on a regular basis.

Internal Audits

As noted above, Enbridge utilizes a combination of its Health Check Process and its Internal Review Process to meet the Board’s OPR requirements. The Board found that this process is deficient; however, the Board reviewed Enbridge’s audit practices and results to determine whether the company was meeting its audit requirements at a program level. During the audit, Enbridge provided documentation and records relating to its program audit practice and number of its program audit activities that it had completed. This included its environmental Health Checks and its Environmental Reviews.

The Board identified that, at the program level, the process in EMS section 5.2, Environmental Audit Review sets the expectations and provides guidance on how to complete Health Checks, Environmental Reviews and audits. As per its documentation, Enbridge uses all of these verification and review processes to assess its conformance with internal and external policies and procedures, and make improvements if necessary.

EMS, section 5.2.1, Health Checks provides further detail on what is expected of an environmental Health Check. Enbridge uses Health Checks to assess its internal conformance, identify areas of non-standard practice and non-compliance and identify opportunities for improvement. Health Checks focus on a selection or sample of a department’s processes and systems. As per Enbridge’s governance processes, the Health Checks are not expected to assess every possible area of departmental operation. Enbridge’s Health Checks documentation indicated that they should include assessment and verification of:

Internal work practices, standards, and areas of confusion or differences of perception;
Work competencies - Ensuring people are appropriately and adequately trained to perform their assigned activities, including any specific training, certifications and qualifications;
Internal work requirements - Observing work procedures and internal policies and procedures; and
Employee behavior - Observing how employees perform tasks.

Enbridge’s environmental protection practices did not include a program level specific process for Health Checks; however, the EMS references the Environmental Review Program Standard, Env-2, dated May 2013. According to this Program Standard, a minimum of one Health Check per facility per region per year should be completed. However, during interviews Enbridge staff indicated that the company’s Regional Analysts must complete two facility Health Checks per region per year, and this requirement is included in their annual individual performance agreements. The Board reviewed records confirming this practice.

The Board reviewed documentation and records outlining the standard content of environmental Health Checks and found that the content focused on the required technical and management content. The Board also identified that, according to the Program Standard, Health Checks do not require the people completing the assessment to use the Environment department’s legal list or the NEB conditions. The Board therefore determined that this process does not provide a standardized means to assure compliance. The following are some of the categories identified as included in an environmental Health Check for a facility:

current versions of the Environmental Policy, OMMs, Waste Management Plans, Vegetation Management Plans, Ozone Depleting Substances Environmental Management Plans, and Environmental Guidelines for Construction;
organized environmental records (permits, monitoring reports, regulator inspection reports, etc.);
vegetation management practices;
land management practices;
waste storage practices;
waste transportation practices;
hazardous materials practices;
potable water; and
specific approvals, licenses and permit conditions.

Enbridge’s documentation indicated that that Environmental Reviews included many of the requirements of Health Checks but included an expanded facility and activity scope included an increased focus on compliance with and of policies, processes, procedures and external requirements. The Board noted that the Environmental Review Program Standard states that in addition to facilities, Environmental Reviews can include right-of-ways, integrity dig sites, pipeline management shops and valve sites. Enbridge uses the Program Standard to ensure that its Environmental Reviews are repeatable, and are conducted according to a set schedule, timeframe and identified roles. Enbridge conducts Environmental Reviews on a 5-year rotation amongst the company’s regions. The Environmental Protection Program is responsible for identifying the objectives, scope, common protocol core and criteria for each Environmental Review. Third-party auditors are responsible for developing the criteria based on provincial and federal legislation, Enbridge policies and NEB requirements. Enbridge uses third-party auditors to lead each environmental review with Enbridge staff providing support.

The Board reviewed two recent Enbridge internal Environmental Reviews. After reviewing the documented Environmental Reviews, the Board identified the following concerns:

The Environmental Reviews indicated that similar findings were being identified in different regions by subsequent audits. This supports the Board’s findings with respect to Enbridge’s preventive action practice when taken into consideration with the Board’s review of all of Enbridge’s records provided during this and concurrent audits. (Examples included hazardous materials storage and documentation issues that were found in 2009, 2011, 2012 and 2013); and
Areas for Improvement are not tracked with respect to management decisions and, where appropriate through to resolution. As an example, in the 2013 Environmental Review, the lack of environmental content within standard Field Inspections was noted. If this issue was appropriately considered and managed it could have led to better compliance by Enbridge.

The Board found that Enbridge’s Environmental Review process has been implemented, and is comprehensive in providing a review of environmental activities. Additionally, the Board noted that Enbridge’s practice of developing Environmental Review specific legal requirements lists for the environmental protection program was a providing this program with an ability to better monitor Enbridge’s compliance requirements. The Board’s review of the program practices and records indicated that they had developed compliance requirement lists at levels of detail that were being monitored and updated on regular basis.

Corrective and Preventive Action Process

During the audit the Board reviewed the documentation and records associated with the corrective and preventive actions resulting from Enbridge’s environmental protection audit processes. The Board found that Enbridge had been developing and tracking corrective action plans for each Environmental Review finding to completion. Enbridge provided records, including photographs, demonstrating its conformance to the process and mitigation of the findings. Review of these and other records; however, indicated that similar findings were being identified in different regions by subsequent audits. As previously noted, this supports the Board’s findings with respect to Enbridge’s preventive action practice when taken into consideration with the Board’s review of all of Enbridge’s records provided during this and concurrent audits.

Summary

The Board found that Enbridge demonstrated that it is conducting many of the activities that are normally contained within a quality assurance program on a regular basis.

The Board also found deficiencies with Enbridge’s Quality Assurance Program from the perspective of definition, design and management.

Enbridge provided several examples of completed audit related activities; however, the Board found deficiencies with respect to the design of the management system audit processes and activities.

The Board also found that Enbridge was not able to demonstrate that it has undertaken audits consistent with the OPR requirements.

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.

Compliance Status: Non-Compliant

4.4 Records Management

Expectations:

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

References:

OPR section 6.5(1)(p)

Assessment:

Governance Records Management

During the Board’s audit, Enbridge provided the Board with a copy of its draft governance Records Management Process. The Board’s review indicated that process incorporated its existing practices along with new requirements within it. The Board could not determine the adequacy of the process as some of the referenced Tier 2 and 3 documents were not provided with Enbridge’s submission. As well, the Board did not find that the process was established or implemented as it was considered by Enbridge to be in draft format and staff interviewed did not refer to it as a required process during interviews. The Board found that Enbridge has not established or implemented a management system process the meets the OPR requirements. This lack of a compliant management system process, however, is not indicative of a lack of formal records management within Enbridge.

The Board found that, at the time of the audit, Enbridge managed its records according to its Records Management Policy. Based on this policy Enbridge had developed its Records Retention Schedule and Records Development and Sustainment Standard that further guided its records practices. In reviewing these documents, the Board found that Enbridge has established practices for generating, retaining and maintaining its corporate records.

The Board’s review of Enbridge’s corporate records management practices identified that the company’s Records Management department is responsible for developing and maintaining the company’s records management requirements and recommended processes and that its individual department managers are responsible for maintaining and implementing processes and practices at the department level. Department managers develop, maintain and implement departmental records procedures that are aligned with the company’s records management requirements. During its audit the Board found that the established requirements and practices were being implemented on a consistent basis and that the existing requirements were incorporated into the draft Records Management Process.

Environmental Protection Program Records Management

The Board identified that Enbridge’s EMS, section 4.9, Control of Environmental Management System Documents describes the program level process for generating, retaining and maintaining records for Enbridge’s Environmental Protection Program. Through interviews and record review during the audit, the Board identified that Enbridge was implementing the processes and practices described to manage the records in its Environmental Protection Program. The Board found that this process provided a consistent method for recording and tracking environmental information, thereby helping to promote environmental performance.

Summary

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 has established and implemented a management system process that meets the OPR requirements.

The Board also found that Enbridge had implemented a consistent records management practice for application across its organization that resulted in appropriate records management practice being implemented at the program and corporate levels.

Compliance Status: Non-Compliant

5.0 Management Review

5.1 Management Review

Expectations:

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

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

References:

OPR sections 6.5(1)(w), (x), 6.6

Assessment:

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

Annual Management Review

Enbridge’s IMS-01, section 4.3, Management System Review Process outlines the management system review process for ensuring that each management system is reviewed annually to confirm that the desired results are being achieved. As detailed in IMS-06, section 6.0, Management System Review, Enbridge’s environmental management representatives complete an annual management system review of IMS-06. This review includes environmental processes, performance objectives, targets and progress. The review may propose changes or additions to performance measures. The review may also identify areas for improvement or emphasis in the upcoming year. The Board reviewed the minutes from Enbridge’s 2013 Environmental Management Review and found that Enbridge had completed an assessment of the activities, results and improvement opportunities in its Environmental Protection program. Enbridge indicated that an additional process, PC-1801, Accountable Officer Report Development Process, is used to evaluate the management system and the output of this evaluation is the Annual Report.

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

IMS-01, Management System Review Process is not fully established; as defined by Enbridge standards, all process steps were considered aspirational;
PC-1801, Accountable Officer Report Development Process is not referenced or inferred in IMS-01 or IMS-06 and thus is not integrated into Enbridge’s management system;
PC-1801, Accountable Officer Report Development Process is not established as per the Board’s working definition (approval date on the document is 21 October 2014); and
While certain tasks are being reviewed by practice or by exception, the IMS-06 annual review process does not include a review of the implementation of the Environmental Protection Program at the Operations level.

Based on the Board’s evaluation of Enbridge’s management system and Environmental Protection program against the requirements, the Board has determined that Enbridge has not established and implemented a process for conducting an annual review of its management system and protection program. Enbridge will have to develop corrective actions to address the described deficiencies.

Management System Evaluation

While the Board has listed this requirement under sub-element 4.1 of the Protocol, Enbridge indicated during the audit that its IMS-01, Management System Review Process is also used to evaluate the adequacy and effectiveness of the company’s management system. When reviewing the content of this governance process, Enbridge indicated that each process within the management system is reviewed to ensure its effectiveness. Enbridge’s IMS-06, Management System Review Process also overviews this requirement. Enbridge has developed an additional process, PC-1701, Management System Evaluation Process. The PC1701 process includes an evaluation of the adequacy and effectiveness of the overall management system. Records provided to demonstrate implementation of these processes include:

2013 Environmental Management Review Meeting Minutes;
2013 Internal Management System Alignment Assessment; and
3^rd Party Assessment (Dynamic Risk) completed in 2013.

Upon reviewing the various processes and records supporting the implementation of a process for evaluating the adequacy and effectiveness of the company’s management system, the Board noted the following:

IMS-01, Management System Review Process is not fully established; as defined by Enbridge standards, all process steps were considered aspirational;
IMS-01, Management Review Process does not include an evaluation of the adequacy of the management system;
PC-1701, Management System Evaluation Process is not referenced or inferred in IMS-01 or IMS-06, and thus is not integrated into Enbridge’s management system;
Internal Management System Alignment Assessment describes assessing adequacy, effectiveness and implementation of processes, but it is based on the OPR requirements and not an evaluation of Enbridge’s management system as designed;
3^rd Party Assessment (Dynamic Risk) is strictly an alignment/compliance assessment to the OPR 6.1-6.6 requirements and does not attest to the adequacy or effectiveness of Enbridge’s management system (IMS 01 et al); and
Records from the IMS-06 Management Review Process could not confirm that the management system has been fully reviewed for adequacy and effectiveness.

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

Annual Report

Enbridge develops an Annual Accountable Officer Report that describes the performance of the company’s management system in meeting the company’s obligations for safety, security and protection of the environment. The report also describes the company’s achievement of its goals, objectives and targets during that year. The company’s performance is measured against the performance measures developed under the management system and any actions taken that year to correct deficiencies identified by the quality assurance program. The PC-1801, Accountable Officer Report Development Process describes the required process for developing the Annual Accountable Officer Report. According to this process, the Annual Accountable Officer Report must “detail the performance of Enbridge LP management system and will cover areas of leadership, performance measures, internal review, management review and corrective actions taken.” The report must also include details about achievement of goals, objectives and targets during that year as assessed through performance measures.

According to the PC-1801, Accountable Officer Report Development Process, Enbridge must complete its Annual Accountable Officer Report, have it signed by the accountable officer, and submit it to the Board no later than April 30 of each year. The Board confirmed that the Annual Accountable Officer Report for the 2013 performance year was signed by the accountable officer and submitted to the Board by 30 April 2014.

Upon review of the Annual Report, the Board noted that the report does reference some internal and external reviews conducted on the management system. The Annual Report also includes a section that describes the actions taken that year to address deficiencies. However, Enbridge’s Annual Report does not specify the deficiencies and action items, and does not focus on the development and status of the management system. While it is important to communicate this information to the Accountable Officer, it is not fully representative of Board’s quality assurance program requirement (see sub-element 4.3). Thus, it is unclear whether the Accountable Officer is aware of the actions taken that year to address deficiencies identified by the quality assurance program. The Board also noted that the deficiencies identified in sub-elements 1.2 and 2.3 need to be addressed in future Annual Reports.

Management Responsibility

Further to the review of these processes and activities, the Board notes that Enbridge has not conducted audits consistent with its OPR obligations. The Board views the responsibility for undertaking these audits as resting with the company’s senior management (as represented by its Accountable Officer) as the annual report developed as per OPR specifically requires review and reporting on aspects of the Quality Assurance Program (specifically including audits) and performance of the management system in meeting its obligations under OPR section 6. Additionally, the Board has made Non-Compliant findings related Sub-elements 1.2 Policy and Commitment Statements and 2.3 Goals, Objectives and Targets that relate to the development of explicit policies and goals required by the OPR. While the Board’s Non-Compliant findings are mitigated by the nature of the deficiencies (implicit inclusion vs. explicit requirements), the Board notes that it is the responsibility of company management to ensure the development and implementation of compliant policies and goals that guide the company’s management system and programs.

Summary

The Board found that Enbridge had developed processes for and undertaken activities relating to its Management Review responsibilities.

The Board also found that Enbridge’s processes did not meet all of the requirements outlined in the OPR.

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

Compliance Status: Non-Compliant

Footnotes

Footnote i

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

Return to footnote i referrer

Footnote 1

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

Return to footnote 1 referrer

Date modified:: 2020-09-29

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Table of Contents

1.0 POLICY AND COMMITMENT

1.1 Leadership Accountability

Expectations:

References:

Assessment:

Accountable Officer

Summary

Compliance Status: Compliant

1.2 Policy and Commitment Statements

Expectations:

References:

Assessment:

Governance Level Policies and Goals and Commitment Statement

Governance Policy

Governance Commitment Statement

Environmental Protection Program Policy and Commitment Review

Environmental Policy

Hazard Reporting and Immunity from Disciplinary Action Policies

Summary

Compliance Status: Non-Compliant

2.0 PLANNING

2.1 Hazard Identification, Risk Assessment and ControlFootnote 1

Expectations:

References:

Assessment:

Governance Level Hazards and Potential Hazards Identification

Governance: Hazard vs Risk

Governance Hazards Inventory

Governance Risk Evaluation

Governance Developing and Implementing Controls

Environmental Protection Program Hazard Identification, Risk Assessment and Control

Environmental Protection Program Hazard Identification

Environmental Protection Program Inventory of Hazards and Potential Hazards

Environmental Protection Program Risk Evaluation

Environmental Protection Program Developing and Implementing Controls

Environmental Protection Program Communicating Controls

Reporting of Hazards, Potential Hazards, Incidents and Near-misses

Environmental Protection Program Data Management System

Summary

Compliance Status: Non-Compliant

2.2 Legal Requirements

Expectations:

References:

Assessment:

Governance: Identifying Legal Requirements

Environmental Protection Program Legal Requirements

Identifying and Monitoring Compliance

Establishing and Maintaining a List of Legal Requirements

Identifying and Resolving Non-Compliances with Legal Requirements

Summary

Compliance Status: Non-Compliant

2.3 Goals, Objectives and Targets

Expectations:

References:

Assessment:

Governance: Goals, Objectives and Targets for Risks and Hazards

Environmental Protection Program Goals, Objectives and Targets for Risks and Hazards

Summary

Compliance Status: Non-Compliant

2.4 Organizational Structure, Roles and Responsibilities

Expectations:

References:

Assessment:

Governance Organizational Structure and Roles and Responsibilities

Governance Annual Evaluation of Resource Need

Environmental Protection Program Organizational Structure and Roles and Responsibilities

Roles and Responsibilities

Annual Evaluation of Resource Need

Summary

Compliance Status: Non-Compliant

3.0 IMPLEMENTATION

3.1 Operational Control-Normal Operations

Expectations:

References:

Assessment:

Governance Developing and Implementing Operational Controls - Normal Operations

Governance Processes for Coordinating, Controlling and Managing the Operational Activities of Employees and other People Working With or On Behalf of the Company

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