Compliance verification activity type: Field Inspection
Team:
Regulated company: Trans Mountain Pipeline ULC
Operating company: Trans Mountain Pipeline ULC
Province(s) / Territory(s):
Discipline(s):
Related events:
Rationale and scope:
Follow-up inspection to INC2020-115, fatality reported on a Trans Mountain construction site. Verify Trans Mountain’s incident response meets legislative requirements and condition fillings; evaluate the need for immediate regulatory action(s). This activity does not include an investigation into the root cause(s) of the fatality, but does include a determination of the immediate causes requiring short-term intervention.
Compliance tool(s) used:
Facilities:
Facility Types
Life-cycle Phases
Regulatory requirements that apply to this activity:
Observation 1 - IOO RRW-001-2020 Amended Measure 1
Date & time of visit: 2020-10-30 16:00
Discipline: Safety Management
Categories:
Facility:
Observations:
IOO was issued to address hazards and potential hazards to the safety of persons. See RRW-001-2020 on file.
Compliance tool used: Inspection Officer Order (IOO)
Regulatory requirement:
Relevant section(s):
Company action required:
Amended IOO:
Due date: 2020-12-11
Date closed: 2021-06-04 Note: the date closed is the date that the inspector completed their review of the company corrective actions for adequacy and determined that no further actions are required.
Reason closed: Requirement met
Compliance achieved: Yes
Observation 2 - IOO RRW-001-2020 Amended Measure 2(a)(b)(c)(d)
Amended IOO
Due date: 2020-11-20
Date closed: 2021-06-28 Note: the date closed is the date that the inspector completed their review of the company corrective actions for adequacy and determined that no further actions are required.
Observation 3 - IOO RRW-001-2020 Amended Measure 3 (a)(b)(c)
Due date: 2020-12-04
Observation 4 - IOO RRW-001-2020 Amended Measure 4
Date closed: 2021-02-08 Note: the date closed is the date that the inspector completed their review of the company corrective actions for adequacy and determined that no further actions are required.
Observation 5 - IOO RRW-001-2020 Amended Measure 5 & 6
Amended IOO5) Conduct an investigation to determine the root cause(s) for the unsafe act or conditions resulting in the worker fatality. The investigation shall include but is not limited to an assessment of immediate, direct and basic causes, including causal, human and organizational factors and shall identify corrective and preventive actions.6) Submit to the CER a copy of the investigation report and an action plan for the implementation of the corrective and preventive actions identified in item 5. A preliminary investigation report is to be filed on or before 13 November 2020, followed by a final report to be filed on or before 11 December 2020.Origianl IOO5) Conduct an investigation to determine root cause for the unsafe act and/or conditions resulting in the worker fatality. The investigation shall include but is not limited to an assessment of immediate, direct and basic causes, including causal, human and organizational factors and shall identify corrective and preventive actions.6) Submit to the CER a copy of the investigation report and an action plan for the implementation of the corrective and preventive actions identified in item 5 on or before 13 November 2020. Amended IOO5) Conduct an investigation to determine the root cause(s) for the unsafe act or conditions resulting in the worker fatality. The investigation shall include but is not limited to an assessment of immediate, direct and basic causes, including causal, human and organizational factors and shall identify corrective and preventive actions.6) Submit to the CER a copy of the investigation report and an action plan for the implementation of the corrective and preventive actions identified in item 5. A preliminary investigation report is to be filed on or before 13 November 2020, followed by a final report to be filed on or before 11 December 2020.Origianl IOO5) Conduct an investigation to determine root cause for the unsafe act and/or conditions resulting in the worker fatality. The investigation shall include but is not limited to an assessment of immediate, direct and basic causes, including causal, human and organizational factors and shall identify corrective and preventive actions.6) Submit to the CER a copy of the investigation report and an action plan for the implementation of the corrective and preventive actions identified in item 5 on or before 13 November 2020. CER Information Request - Trans Mountain Unified Hazard and Risk RegisterThe CER requires confirmation that the Unified Hazard and Risk Management Procedure (UHRMP) has been fully implemented for hazards with a residual risk rating of high or extreme. Where the UHRMP has not been fully implemented, the CER requires a list of any identified high or extreme hazards and specifically, what component of the process has not been implemented in each case.
Due date: 2020-12-18
Date closed: 2020-12-22 Note: the date closed is the date that the inspector completed their review of the company corrective actions for adequacy and determined that no further actions are required.
Observation 6 - IR#1 - Safe Work Procedures, Trench Boxes, as per SA Energy Group PSSP.
Compliance tool used: Information Request (IR)
File immediately to the CER - the document as referenced in SA Energy Group, PSSP #01-13283-S4B-M002-HS-PLN0002 RC, 2019-04-29;
Due date: 2020-11-03
Date closed: 2020-11-03 Note: the date closed is the date that the inspector completed their review of the company corrective actions for adequacy and determined that no further actions are required.
Observation 7 - General Observations - October 28, 2020
Date & time of visit: 2020-10-28 09:20
October 28, 2020, 9:20 - TMEP Spread 1 Construction Yard
Compliance tool used: No compliance tool used
Observation 8 - General Observations - October 29, 2020
Date & time of visit: 2020-10-29 08:30
General Observations - October 29, 2020, 08:30CER IOs met TMEP Reps at the TMEP Spread 1 Construction Yard to continue regulatory inspection of post incident activities
Observation 9 - General Observations - October 30, 2020
Date & time of visit: 2020-10-30 11:30
General Observations - October 30, 2020, 11:30am.CER IOs met TMEP Reps at the TMEP Spread 1 Construction Yard to continue regulatory inspection of post incident activities
Observation 10 - General Observations – October 31, 2020
Date & time of visit: 2021-10-31 09:00
General Observations – October 31, 2020 9:00amCER IOs travelled to Whitemud Creek HDD site to perform field observations:
Observation 11 - NNC 1 - manufacturer's instructions
Date & time of visit: 2020-10-29 14:30
Trans Mountain has committed to ensuring all legal requirements are complied with on the spread including provincial occupational health and safety legislation (Trans Mountain Health and Safety Management Plan, s. 5.1) which requires equipment be assembled and dismantled in accordance with the manufacturer's specifications, or specifications certified by a Professional Engineer. On 27 Oct 2020 contracted workers were tasked with dismantling a trench box on shoofly 38a in Edmonton, AB. The equipment was not dismantled in accordance with the manufacturer’s instructions. This finding is supported by observations made by CER Inspection Officers (IOs) between 28 Oct 2020 and 30 Oct 2020 including:
Compliance tool used: Notice of Non-compliance (NNC)
Due date: 2021-03-31
Date closed: 2021-06-01 Note: the date closed is the date that the inspector completed their review of the company corrective actions for adequacy and determined that no further actions are required.
Observation 12 - NNC 2 - construction safety manual accessibility
Date & time of visit: 2020-10-30 15:45
On 30 Oct 2020 CER Inspection Officers(IO) requested from a Trans Mountain Field Safety Inspector (FSI) a copy of a safe work procedure(SWP) for 'Trench Boxes', identified in the on site SA Energy Group's, Project Specific Safety Plan (PSSP) (Document #01-13283-S1-M002-HS-PLN-0002 R3, dated 2020-05-28). The FSI was not able to provide a copy or produce a digital version of this SWP. A digital copy of the SWP was provided on 3 Nov 2020.
Provide confirmation that the construction safety manual (CSM) or the relevant parts of it are available to every person engaged in construction activities across the Trans Mountain Expansion Project.
Observation 13 - NNC 3 - hazard identification and control
CER Inspection Officers (IO) learned through interview that workers are commonly tasked with the assembly and disassembly of trench boxes on Spread 1. Despite the fact that assembly and disassembly of trench boxes often involves mechanical lifting and workers in the 'line of fire' (two of Trans Mountain's Life Saving Rules), IOs found no evidence that hazards specifically related to the assembly or disassembly of GroundWorks High Arch trench boxes were identified during the risk assessment process.
Applicable to the Trans Mountain Expansion Project, provide evidence that the hazards related to the assembly, disassembly, and use of trench boxes have been identified, analyzed, and mitigated including how the mitigations are communicated to workers.
Observation 14 - NNC 4 - Life Saving Rules program
Date & time of visit: 2020-10-30 08:00
CER Inspection Officers discovered through interview, Trans Mountain Expansion Project (TMEP) employees could not speak to, or effectively explain the concept of the Life Saving Rules, as were to be applied at the Spread 1 project area.
Pursuant to TMEP Document #01-13283-GG-0000-HS-PLN-0029, 'Life Saving Rules', demonstrate to the Inspection Officer how implementation, adoption of, and quality control for the use of the Life Saving Rules, is effectively functioning on the TMEP project.
Date closed: 2021-05-26 Note: the date closed is the date that the inspector completed their review of the company corrective actions for adequacy and determined that no further actions are required.
Observation 15 - NNC 5 - training
Date & time of visit: 2020-10-29 13:30
CER Inspection Officers discovered through worksite observation and employee interview(s), that workers responsible to assemble, handle, use and disassemble Groundworx High Arch trench boxes, had not received adequate training to safely do so.This finding is supported by observations made by CER Inspection Officers (IOs) between 28 Oct 2020 and 30 Oct 2020 including:
Trans Mountain Expansion Project (TMEP) is provide and demonstrate to the Inspection Officer, that adequate, standardized and manufacturer aligned training, will be delivered to persons handling, assembling, using and disassembling trench boxes; that satisfies the requirement of OPR regulation 6.5(1)(j).This Notice of Non-Compliance is in alignment with and supported by IOO Specified Measure "IOO RRW-001-2020 Amended Measure 2(a)(b)(c)(d)"; and may be reviewed in congruence with response to IOO RRW-001-2020 Amended Measure 2(a)(b)(c)(d).
Date closed: 2021-05-31 Note: the date closed is the date that the inspector completed their review of the company corrective actions for adequacy and determined that no further actions are required.
Identified non-compliances to company plans or procedures are non-compliances either to:
- the condition of an authorization document that requires the implementation of that plan or procedure; or
- the relevant section of the regulations that requires implementation of that plan or procedure including those sections that require implementation of plans or procedures as a part of a Program
