Montreal Pipe Line Limited - Emergency Management Program CV2526-022
Montreal Pipe Line Limited - Emergency Management Program CV2526-022 [PDF 687 KB]
Executive Summary
The Canada Energy Regulator (CER) expects pipelines and associated facilities within the Government of Canada’s jurisdiction to be constructed, operated, and abandoned in a safe and secure manner that protects people, property, and the environment. To this end, the CER conducts a variety of compliance oversight activities, such as audits.
Section 103 of the Canadian Energy Regulator Act (S.C. 2019, c.28, s.10) (CER Act) authorizes inspection officers to conduct audits of regulated companies. The purpose of these audits is to assess compliance with the CER Act and its associated Regulations.
The purpose of operational audits is to ensure that regulated companies have established and implemented both a management system and its associated programs, as specified in the Canadian Energy Regulator Onshore Pipeline Regulations (SOR/99-294) (OPR).
The CER conducted a Emergency Management (EM) operational audit of Montreal Pipe Line Limited (the company or MPLL) between 7 April 2025 and 6 August 2025.
The objective of this audit is to verify that the company has developed and implemented specific elements of an EM program in accordance with the requirements of the OPR related to:
- Hazard identification;
- Risk assessment;
- Making employees and others aware of their responsibilities;
- Internal and external communication;
- Contingency planning; and
- Management of documentation.
Of seven audit protocols; three were deemed no issues identified. The remaining were deemed non-compliant. Overall, the CER auditors identified gaps within several process documents related to hazard identification and analysis, documentation management, and internal communication. While the company is doing a lot of activities, they are not necessarily being done according to a documented and repeatable process as required by the OPR.
The findings from the audit are summarized in Table 2 and explained in detail in Appendix 1 of this report.
Within 30 calendar days of receiving the final audit report, the company shall file with the CER a corrective and preventive action (CAPA) Plan that outlines how the non-compliant findings will be resolved. The CER will monitor and assess the implementation of this CAPA Plan to confirm that it is completed in a timely manner.
Note that all findings are specific to the information assessed at the time of the audit as related to the audit scope.
While non-compliant findings exist, the CER finds that the company can still construct, operate, and abandon pipelines in a manner that will preserve the safety of persons, the environment, and property.
The final audit report will be made public on the CER website.
Table of Contents
- Executive Summary
- 1.0 Background
- 2.0 Objective and Scope
- 3.0 Methodology
- 4.0 Summary of Findings
- 5.0 Discussion
- 6.0 Conclusion
- 7.0 Next Steps
- Appendix 1: Audit Assessment
- Appendix 2: Terms and Abbreviations
List of Tables and Figures
- Figure 1. Map of Montreal Pipe Line Limited Regulated Assets
- Table 1. Audit Scope
- Table 2. Summary of Findings
1.0 Background
1.1 Introduction
The CER expects pipelines and associated facilities within the Government of Canada’s jurisdiction to be constructed, operated, and abandoned in a safe and secure manner that protects people, property, and the environment.
Section 103 of the CER Act authorizes inspection officers to conduct audits of regulated companies. The purpose of these audits is to assess compliance with the CER Act and its associated Regulations.
The purpose of operational audits is to ensure that regulated companies have established and implemented both a management system and its associated programs, as specified in the OPR.
The CER conducted an Emergency Management (EM) operational audit of MPLL between 7 April 2025 and 6 August 2025.
1.2 Description of Audit Topic
The CER expects companies to have a fully established and implemented EM program. This program is expected to proactively address the various scenarios, contingencies, and related actions that are necessary to be taken to protect the public, workers, and the environment during all potential upset or abnormal operating conditions experienced by the company. These upset or abnormal operating conditions can take place at any point during a pipeline or facility’s lifecycle and in any season or weather event. As part of the establishment and implementation of the Emergency Management program, the CER expects the company’s management system to be integrated into this program and linked to other OPR section 55 programs as necessary to have robust controls in place to manage and mitigate any upset or abnormal conditions that may occur.
1.3 Company Overview
MPLL has an 80-year operating history having started operations in 1941. MPLL’s parent company is Suncor Energy Inc. whose Montreal refinery is connected to this system. The MPLL Canadian footprint traverses approximately 232 kilometres from the international border near Highwater, Quebec to the Montreal-East Terminal. MPLL controls three pipelines all in the same right-of-way. A 24 inch pipeline currently provides crude oil from Portland, Maine to the Montreal-East Terminal. It also has an 18inch pipeline which is currently nitrogen-filled and was deactivated in 2011, and a 12-inch pipeline which is nitrogen-filled and abandoned.
The map below depicts the company’s CER-regulated assets.
2.0 Objective and Scope
The objective of this audit is to verify that the company has developed and implemented specific elements of an emergency management program in accordance with the requirements of the OPR related to:
- Hazard identification;
- Risk assessment;
- Making employees and others aware of their responsibilities;
- Internal and external communication;
- Contingency planning; and
- The management of documentation.
The table below outlines the scope selected for this audit.
Table 1. Audit Scope
Audit Scope |
Details |
|---|---|
Audit Topic |
Emergency Management |
Lifecycle Phases |
x Operations
|
Section 55 Programs |
x Emergency Management
|
Time Frame |
Open |
3.0 Methodology
An audit notification letter was sent to the company on 7 April 2025 advising the company of the CER’s plans to conduct an operational audit. The lead auditor provided the audit protocol and initial information request to the company on 16 April 2025 and followed up on 25 April 2025 with a meeting with the company staff to discuss the plans and schedule for the audit. Document review began on 26 May 2025 and interviews were conducted between 16 June 2025 and 25 June 2025. An EM exercise was attended on 14 May 2025.
The auditors assessed compliance through:
- document reviews;
- record sampling;
- interviews; and
- attendance at an EM exercise.
The purpose of the document review is to identify the suite of documents that are intended to meet the requirements related to the audit protocols. This review assesses whether the process is established. The auditors reviewed approximately 80 documents.
The interviews are conducted to determine the extent to which the processes have been implemented. If the responses are consistent with what is written, the auditors assume that the staff are aware of the process, and that it is being followed. The first set of interviews was conducted primarily with management and senior staff to discuss each of the audit protocols. The second set of interviews was organized based on positions, which ranged from office staff to field staff, where the auditors asked questions relating to all the audit protocols at each interview. The auditors conducted 9 interviews.
Records are also sampled to assess whether the process is implemented. Records are outputs, or products of a process. The presence of properly completed records suggests that the process is being used. The auditors sampled approximately 21 records.
The list of documents reviewed, records sampled, and the list of interviewees are retained on file with the CER.
In accordance with the established CER audit process, the lead auditor shared a pre-closeout summary of the audit results on 17 July 2025. At that time, the company was given six business days to provide any additional documents or records to help resolve the identified gaps in information or compliance. Subsequent to the pre-closeout meeting, the company provided additional information to assist the lead auditor in making their final assessment of compliance. The lead auditor conducted a final closeout meeting with the company on 6 August 2025.
4.0 Summary of Findings
The lead auditor has assigned a finding to each audit protocol. A finding can be either:
- No Issues Identified – No non-compliances were identified during the audit, based on the information provided by the company and reviewed by the auditor within the context of the audit scope; or
- Non-compliant – The company has not demonstrated that it has met the legal requirements. A CAPA Plan shall be developed and implemented to resolve the deficiency.
All findings are specific to the information assessed at the time of the audit, as related to the audit scope.
The table below summarizes the findings. See Appendix 1: Audit Assessment for more information.
Table 2. Summary of Findings
| Audit Protocol (AP) Number | Regulation | Regulatory Reference | Topic | Finding Status | Finding Summary |
|---|---|---|---|---|---|
AP-01 |
OPR |
6.5(1)(c) |
Hazard Identification |
Non-compliant |
MPLL’s process fails to identify hazards and potential hazards as required by the OPR following a sequential stepped approach of hazard and potential hazard identification. The MPLL process and procedures, while mentioning harm and hazard, instead focus on risk and risk assessment. |
AP-02 |
OPR |
6.5(1)(d) |
Hazard Inventory |
Non-compliant |
MPLL was able to provide an inventory, unfortunately the inventory was made up of risks rather than hazards and potential hazards. In addition, the company did not demonstrate how the inventory links to the hazard and analysis process and the risk evaluation and controls processes. |
AP-03 |
OPR |
6.5(1)(e) |
Risk Assessment |
No Issues Identified |
After reviewing the risks associated with the EM program, the auditors are of the opinion that all risks have been assigned a risk likelihood, impact, and threshold rating, for both inherent risk and for residual risk and risk mitigation plans are in place for risks that reach the critical level 1 criteria. When reviewing the Emergency Management Program (EMP) it is evident that the emergency response procedures are linked with and apply the requirements of MPLL’s Risk Management Element. |
AP-04 |
OPR |
6.5(1)(l) |
Making Employees and Others Aware of their Responsibilities |
No Issues Identified |
MPLL, through its Integrated Contingency Plan (ICP) and EMP documents, has a process that ensures all staff and contractors are aware of their respective responsibilities. MPLL builds on this with links to its training and competency activities especially with respect to the EM Program and its training requirements. |
AP-05 |
OPR |
6.5(1)(m) |
Internal and External Communications |
Non-compliant |
MPLL does not have a communications process that addresses internal communication, which is mandatory and repeatable. By activity, MPLL has many of the aspects that would be expected of a communications process, however it relies on the actions and the memory of its well-trained and experienced staff to follow through on them. If these staff were to leave, it could create a knowledge gap that would allow mistakes to take place and the existing plans to fail. |
AP-06 |
OPR |
6.5(1)(o) |
Document Management |
Non-compliant |
MPLL does identify the ICP as a critical document and a key part of its documentation related to the overall EM program, and it is kept up to date. However, the process does not explicitly point to the authorizing person(s) who are allowed to provide sign off on all documentation. In addition, while the Element process requires the Element Champion to review and update the processes and procedures that make up each Element on a three year cycle the CER auditors identified numerous documents where this is not being done. This is both a non-compliance to the OPR requirement and a non-conformance to MPLL’s internal documented requirements. |
AP-07 |
OPR |
6.5(1)(t) |
Contingency Planning |
No Issues Identified |
Through its detailed ICP, MPLL has demonstrated that it has developed and implemented the required processes and procedures to achieve the expected outcomes required of this OPR paragraph. |
5.0 Discussion
Montreal Pipe Line Limited is also known as the Portland Montreal Pipe Line (PMPL) when combining both the Canadian and American segments of the system. However, as this operational audit is only looking at the Canadian operations, this audit report will refer to it as either MPLL or the company. MPLL indicated its management system has been in place since 1994, predating the regulatory requirements found in the OPR.
The MPLL management system is known as the Portland Montreal Integrity Managing System (PMIMS). The PMIMS consists of 11 elements and 21 sub-elements, including coordinating processes, procedures, and tools, which are applied to all projects, programs, operational, and non-operational phases of work. One of the PMIMS protection programs is the EM program, with the EM program document describing the interrelationship of the program to the PMIMS. The PMIMS states that As a management system, PMIMS is designed to balance and connect the organization in how it operates, makes decisions, evaluated risk, communicates to its stakeholders, achieves performance goals, and facilitates organizational learning and change. The PMIMS is implemented through PMPL’s Protection Programs to minimize and manage related compliance and risks associated with PMPL’s Operations, and Projects. The MPLL Protection Programs are designed to implement the PMIMS requirements within their specific scope and attributes.
The PMPL EMP document states, The Programs are implemented within the PMPL work structure through both formal and informal mechanisms, processes, and systems that enable the accomplishment of the company program base requirements (emphasis added). The CER auditors are concerned about the use of informal mechanisms, processes, and systems. These informal activities may work successfully today; however, if they are not formally acknowledged and documented, they are not considered to be sequential and repeatable steps that can be carried out by competent staff entrusted with that specific activity on an ongoing basis, as required by the OPR. Several findings in this audit may be attributable to these informal mechanisms and processes that need to be formalized.
Overall, the CER auditors are of the opinion that MPLL’s staff is well-trained and competent from an EM perspective as that is the only program reviewed as part of this audit. However, it appears the staff are using some informal processes and procedures to complete all of the tasks required by the management system. While the tasks are being completed, it is not necessarily always done following documented and fully implemented processes.
In the documentation provided to the CER auditors is a statement indicating the PMIMS is to serve as the MPLL Safety and Loss Management System which is a requirement of the CSA document Z662:23. CSA Z662:23 is most current version of the Canadian technical standard for oil and gas pipeline systems. While the CSA Safety and Loss Management System requirement, if followed correctly, will generate a pipeline management system, it does not necessarily meet all of the management system requirements in section 6 of the OPR. This audit is conducted following the OPR requirements and, as a result, gaps were identified in MPLL’s management system as it may not have been designed to meet all of the CER’s requirements.
The CER auditors spent a considerable amount of time assessing MPLL’s requirements relating to hazard identification and risk assessment. The CER auditors consider this as one of the fundamental pillars to having a successful management system. The CER auditors also look at these two terms as linking to one another, but each having its own definition. When reviewing the MPLL management system, it appears that it uses these two terms interchangeably when they are not. This resulted in significant confusion when trying to fully understand the MPLL management system and led to non-compliances in this audit.
MPLL provided a significant amount of information related to its EM program, and its management system for CER auditors to review. Overall, the information provided, in the CER auditors opinions, indicates that MPLL has taken steps towards an OPR-compliant management system, but gaps still exist in its overall structure. Some of the findings in the audit are similar to findings from an earlier CER audit conducted in 2018 on MPLL’s integrity management program. Both audits found issues with respect to hazards and hazard identification. To ensure similar findings are not identified in a subsequent audit, the CER auditors strongly encourage MPLL to take these audit findings and apply them to all of the protection programs and not just the EM program which is all that the CER auditors reviewed in this audit. MPLL staff interviewed were well informed and knowledgeable about the EM program as well as their specific roles. Unfortunately, MPLL was unable to produce records for all sampling requests as some of its activities, such as some types of risk assessments, have not been conducted for the EM program in the last two years. As a smaller company, MPLL has not had a need to use all of its available tools in the last two years, which means there were no records available for CER auditors to review. This did not result in any non-compliant audit findings but can be an indicator that MPLL’s EM activities are not required on a frequent basis.
MPLL indicated that it uses the National Incident Management System, or the Incident Command System (ICS) to manage emergency response activities. MPLL is of the opinion that using the ICS during an emergency is the best way to ensure an efficient response when there are various jurisdictions, or other boundaries involved. The ICS is a system that can be easily adapted from very small incidents to those of considerable size, scope, and impact. MPLL’s ICP states The ICS is a system whereby all Company, contractor and local community emergency response, and other facilities, equipment, personnel, procedures, and communications are coordinated and controlled through a unified command system. MPLL’s ICP indicates that it will be implemented for all discharge incidents with staffing levels adjusted as needed to meet the scale and magnitude of the incident in question. The ICP indicates that MPLL response team members will receive ICS training and potentially additional supplemental training if warranted.
As part of this audit, two CER staff members participated in an MPLL emergency exercise on 14 May 2025 in Brigham, Quebec. The exercise scenario simulated the release of oil into the Yamaska River, and exercise activities involved boom deployment and decontamination of responders at a control point near the Chemin des Érables. The exercise was carried out successfully and was resourced with competent staff and contractors that were familiar with MPLL emergency response actions, demonstrating the company’s ability to response to a spill scenario. Opportunities for improvements were identified and the lessons learned will be incorporated into future training and response planning to further strengthen readiness. No notice of non-compliance was issued during the emergency exercise.
CER auditors reviewed MPLL’s compliance history, which included the CER audit of the company’s integrity management program in 2018. In review of this past audit, the auditors found a non-compliant finding related to hazard identification in the 2018 audit that appears to be repeated in this audit. Companies are expected to use audit findings to improve their management system and as such, repeated non-compliances may result in additional compliance oversight by the CER in the future.
6.0 Conclusion
In summary, the CER conducted an operational audit of MPLL related to Emergency Management. Out of a total of seven audit protocols, three were classified as no issues identified, resulting in an audit score of 43 percent.
While MPLL has many formal and informal processes associated with its management system, gaps in hazard identification, and documentation management exist when compared to the OPR requirements.
MPLL is expected to resolve these deficiencies through the implementation of a CAPA Plan. The CER will monitor and assess the implementation of this CAPA Plan and issue an audit closeout letter upon its completion.
7.0 Next Steps
The company is required to resolve all non-compliant findings through the implementation of a CAPA Plan. The next steps of the audit process are as follows:
- Within 30 calendar days of receiving the final audit report, the company shall file with the CER, a CAPA Plan that outlines how the non-compliant findings will be resolved.
- The CER will monitor and assess the implementation of the CAPA Plan to confirm that it is completed:
- on a timely basis; and
- in a safe and secure manner that protects people, property, and the environment.
- Once implementation is completed, the CER will issue an audit closeout letter.
Appendix 1: Audit Assessment
AP-01 - Hazard Identification
Finding Status |
Non-compliant |
Regulation |
OPR |
Regulatory Reference |
Paragraph 6.5(1)(c) |
Regulatory Requirement |
A company shall, as part of its management system and the programs referred to in section 55, establish and implement a process for identifying and analyzing all hazards and potential hazards. |
Expected Outcome |
|
Relevant Information Provided by the Company |
The following key documents and records are related to this finding:
The following interviews are related to this finding:
|
Finding Summary |
In summary, MPLL’s process fails to identify hazards and potential hazards as required by the OPR following a sequential stepped approach of hazard and potential hazard identification The MPLL process and procedures, while mentioning harm and hazard, instead focus on risk and risk assessment. |
Detailed Assessment
MPLL pointed to its Element 2 – Risk Management process as the document for this Audit Protocol requirement. The document goes on to say its purpose is to manage risks to safety, security, health and the environment, and the potential financial impact for all PMPL operations. The objective of the document is to reduce the number and severity of incidents that cause harm to people and/or the environment and loss of PMPL facilities integrity.
The process outlined in this document requires a risk assessment and hazard identification step based on performing a higher-level risk assessment (HLRA), which is to be completed at a minimum every 3 years. The Element 2 Risk Management process indicates that the HLRA is […] to identify areas of potential risk so that formal risk assessments can be scheduled and performed in a prioritized manner. MPLL demonstrated that it has been doing these HLRAs since 1994 on various risks that have the potential to impact the EM program. Over time these HLRAs have become more focused and provide greater clarity to MPLL staff on what they need to be aware of and the actions they need to be taking. The guidelines for conducting HLRAs are well documented. The Element 2: Conducting the Higher-Level Risk Assessment document was shared with the CER auditors along with several examples of completed HLRAs to demonstrate that the process and HLRA guidance have been used.
At the program level, the PMPL EMP describes how Element 2: Risk Management specifically relates to the EMP and linkages to processes such as the HLRA are documented. MPLL provided its inventory of hazards that included EMP items to demonstrate that key hazards that impact the EMP are identified using the processes in Element 2. The inventory will be further discussed below in the next audit protocol (AP-02).
After reviewing the documentation provided by MPLL, the auditors are of the opinion that MPLL does not have an established and implemented process for identifying and analyzing all hazards and potential hazards. Neither the CER Act nor the OPR have a definition for hazard, however the CSA Z662:23 standard defines it as a condition or event that might cause a failure or damage incident or anything that has the potential to cause harm to people, property, or the environment. This CSA standard is directly referenced through section 4 of the OPR and is to be followed as part of a company’s overall compliance to CER requirements. In the opinion of the CER auditors, MPLL did not have anything in their process or procedures documents that would align with this definition and how it should be applied. MPLL’s process appears to jump directly to identifying areas of potential risk, risk assessment, and then assigning controls to manage and mitigate those risks.
CER auditors also noted that MPLL is interchangeably using the words hazard and risk in its documentation, but they have different meanings and have different requirements under the OPR. For example, the PMPL EMP document states that hazards may vary depending upon the location and nature of the work activities, thereby requiring assessment prior to commencing work and ensuring personnel are aware of the site-specific hazards, and are equipped to support the planned activities. It is the responsibility of the department head to conduct the risk assessment and ensure that Emergency Response Plans are aligned with the risks identified (emphasis added). The use of both hazard and risk together or interchangeably can lead to confusion in implementing the process. As a result, MPLL could not demonstrate that it has identified (and analyzed) all hazards and potential hazards.
The other part of this audit protocol that is not addressed in MPLL’s documentation is the need to assess for potential hazards. The CER auditors did not note any mention of potential hazards while assessing this audit protocol.
The PMPL EMP indicates that it uses the ICS to respond to serious incidents. Consistent with ICS, the PMPL EMP lists the priorities by which the company will respond to an incident, which are:
- Life safety;
- Incident stabilization; and
- Conservation of property and the environment.
Using the ICS, MPLL focuses the emergency response around developing objectives, strategies, and tactics to identify and address the risks that threaten these priorities. The MPLL ICP also lists the various roles in the emergency response and their responsibilities.
As raised in the Discussion section of this report, the non-compliance in this audit protocol is similar to the one that was identified in the 2018 MPLL integrity management audit. While the problem was addressed through a CAPA Plan for the integrity management program, it does not appear the fix was extended to all of the other section 55 OPR protection programs.
In summary, CER auditors found that MPLL does not have a compliant hazard identification and analysis process as required by this audit protocol because its process appears to jump directly to identifying areas of potential risk and conducting a risk assessment. The MPLL process and procedures, while mentioning harm and hazard, instead focus on risk and risk assessment. While this is important, it does not address the requirement for this specific audit protocol.
AP-02 Hazard Inventory
Finding Status |
Non-compliant |
Regulation |
OPR |
Regulatory Reference |
Paragraph 6.5(1)(d) |
Regulatory Requirement |
A company shall, as part of its management system and the programs referred to in section 55, establish and maintain an inventory of the identified hazards and potential hazards. |
Expected Outcome |
|
Relevant Information Provided by the Company |
The following key documents and records are related to this finding:
The following interviews are related to this finding:
|
Finding Summary |
In summary, CER auditors found that MPLL’s inventory was made up of risks rather than hazards and potential hazards, as required by the OPR. In addition, the company did not demonstrate how the inventory links to the hazard and analysis process and the risk evaluation and controls processes. |
Detailed Assessment
MPLL provided the EM portion of its hazard inventory to demonstrate that it has an inventory of its hazards for the EM program that has been established and is being maintained. The inventory demonstrated that MPLL has been updating and maintaining this inventory from 1994 through 2023 when the last entries were made. During interviews, MPLL’s complete hazard inventory was also shown on screen to demonstrate where the EM items were pulled from. MPLL representatives explained that the inventory consists mainly of copied content from the HLRAs.
While MPLL’s version of its hazard inventory is updated every three years, it is, however, made up with risks or risk scenarios and not hazards as required by the OPR. This is noted in the Element 2 Risk Management document where it states The hazards inventory is made of all the risks that have been identified throughout the previous HLRA’s and formal risk assessments and through other processes as determined by the Element 2 Champion (emphasis added).
While MPLL’s version of its hazard inventory is updated every three years, it is being updated with risks and not hazards as required by the OPR.
CER auditors also noted that the linkage between the process required under paragraph 6.5(1)(c) of the OPR and the hazard inventory was not evident. The inventory appeared to function in isolation, separated, or disconnected from the process and not part of the integrated management system. In addition, it wasn’t clear in MPLL’s documentation how the inventory was being used as part of the risk evaluation and controls processes. To meet the requirements of the OPR, those processes and the inventory must be interlinked with one another and work together as part of the larger management system requirement of identifying hazards and potential hazards, assessing risk, and implementing controls as needed.
In summary, CER auditors found that MPLL’s inventory was made up of risks rather than hazards and potential hazards as required by the OPR. In addition, the company did not demonstrate how the inventory links to the hazard and analysis process and the risk evaluation and controls processes.
AP-03 Risk Assessment
Finding Status |
No issues identified |
Regulation |
OPR |
Regulatory Reference |
Paragraph 6.5(1)(e) |
Regulatory Requirement |
A company shall, as part of its management system and the programs referred to in section 55, establish and implement a process for evaluating the risks associated with the identified hazards and potential hazards, including the risks related to normal and abnormal operating conditions. |
Expected Outcome |
|
Relevant Information Provided by the Company |
The following interviews are related to this finding:
|
Finding Summary |
In summary, after reviewing the risks associated with the EM program, the auditors are of the opinion that all risks have been assigned a risk likelihood, impact, and threshold rating, for both inherent risk and for residual risk and risk mitigation plans are in place for risks that reach the critical level 1 criteria. When reviewing the PMPL EMP it is evident that the emergency response procedures are linked with and apply the requirements of MPLL’s Risk Management Element. |
Detailed Assessment
MPLL staff pointed to the Element 2 Risk Management document where the process for this audit protocol requirement is found. The document states a HLRA of all facilities and infrastructures, including internal and external interfaces is performed every 3 years, or more frequently as required, to identify areas of potential risk so that formal risk assessments can be scheduled and performed in a prioritized manner. MPLL indicated the process applies to all section 55 protection programs identified in the OPR, but this audit only assessed against the EM program.
The Element 2 Risk Management document also states that the HLRA categorizes for probability and severity all identified risks using the Risk Matrix Tool. The Probability axis of the matrix is broken down into five level, from A – possibility of repeated incidents to E – Practically impossible. The Severity scale goes from four (IV - Insignificant) to one (I - Catastrophic). Identified risks or incident scenarios being assessed for risk require that a severity and a probability score be assigned for each consideration area - Health/Safety, Environmental Impact, Public Impact, Financial Impact, and Regulatory Impact - based on their own specific criteria. Upon assessing probability and severity, MPLL is interpreting risk significance into risk categories - Category 1 being higher risk and Category 4 being lower risk. CER auditors are of the view that this approach is appropriate for the nature, scope, scale, and complexity of MPLL’s limited activities.
MPLL provided examples of completed HLRAs for review, which showed that risk scenarios impacting the EM program were rated for probability and severity using the risk matrix, along with the Risk Category. There is a first assessment that is done with no controls in place that provides the base level of risk that has nothing in place to mitigate any possible outcomes that may arise (inherent risk). If this base risk level is determined to be too high, then various controls are applied in an effort to reduce the risk to an acceptable level, and the risk assessment process is completed a second time considering these various controls to determine a residual risk level. MPLL indicated that it uses its Enterprise Risk Management framework to monitor risk levels over time and verify if the current mitigating controls and measures are still effective. An assessment is not considered complete until a management approved report is issued. The Element 2 Risk Management document indicates that any scenario, condition, or event assessed to be a Category 1 risk is reviewed with Senior Management Team and the PMPL Board of Directors. The PMPL President must review and endorse continued operation of Category 1 risks initially and quarterly thereafter.
During interviews of MPLL staff, the auditors asked how MPLL accounts for abnormal operating conditions as required by this paragraph of the OPR. MPLL staff indicated that abnormal operating conditions are addressed using their all-hazard approach. Abnormal operating conditions are reviewed during ongoing formal risk assessments and as needed through emergency planning. As part of ongoing operations and maintenance and the consideration of abnormal events, Element 6 states Critical operating and maintenance procedures are those procedures or circumstances, whether it is normal or abnormal, which elevates the safety, security, health or environmental, or business risk of the operation, and the Director of Operations and Quebec Area Manager will ensure that a sign-off system is in place and complied with for critical operating and maintenance procedures.
From a program-level perspective, CER auditors noted that MPLL provided a significant amount of information in its ICP on the risks associated with its operations. The MPLL ICP provides response plans that are each individually designed to respond to or mitigate these risks. For example, specific response plans for areas of vulnerability, such as rivers and creeks along the MPLL system and facilities, have been developed and outline factors such as:
- Environmental and socio-economic sensitivities of the area around the pipeline;
- The specific land characteristics of the area around the pipeline;
- Water flow velocities;
- Location of water intakes (if present);
- Parks and campgrounds in the vicinity of the pipeline; and
- Historical weather information.
This is not a complete list, but an example of what the ICP section on response plans contains for all significant vulnerable areas along the pipeline right-of-way. This information provides an effective starting point for MPLL staff when an ICS response is being contemplated, including what specific roles within the ICS system will need to be staffed.
The ICP also addresses safety hazards and risks in the context of an emergency, where the safety representative will be responsible for preparing a site safety and health plan that will set site-specific policies, practices, and procedures to protect workers and the public from potential exposure to chemicals of concern and address physical hazards. The site-specific safety and health plan will contain the following information, among other details:
- A characterization of the risks associated with each operation that will be conducted in the area covered by the plan;
- A description of known chemical and physical hazards, and the measures that have been instituted to eliminate the hazards or reduce them to an acceptable level; and
- Guidance on who is responsible for monitoring site safety.
Once developed, the Operations Section Chief will activate and execute the plan during an emergency. Additionally, the Operations Section Chief will ensure the safety of all personnel in collaboration with the Safety Officer.
In summary, MPLL demonstrated that it has implemented its Element 2 Risk Management document, including abnormal operating conditions which are built into MPLL’s processes that apply to its EM program. After reviewing the risks associated with the EM program, the auditors are of the opinion that all risks have been assigned a risk likelihood, impact, and threshold rating, for both inherent risk and for residual risk, and risk mitigation plans are in place for risks that reach the critical level 1 criteria. There was also evidence of linkages between the PMPL EMP and MPLL’s Risk Management Element.
AP-04 Making Employees and Others Aware of their Responsibilities
Finding Status |
No issues identified |
Regulation |
OPR |
Regulatory Reference |
Paragraph 6.5(1)(l) |
Regulatory Requirement |
A company shall, as part of its management system and the programs referred to in section 55, establish and implement a 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 this section. |
Expected Outcome |
|
Relevant Information Provided by the Company |
The following key documents and records are related to this finding:
The following interviews are related to this finding:
|
Finding Summary |
In summary, MPLL, through its ICP and EMP documents, has a process that ensures all staff and contractors are aware of their respective responsibilities. MPLL builds on this with links to its training and competency activities especially with respect to the EM Program and its training requirements. |
Detailed Assessment
MPLL pointed to its Element 5 Safety, Training and Personnel as the process to meet this audit requirement. This document states that the objective is to have employees and other persons who work with or on behalf of the Company that are fully trained with the required knowledge, skills, and abilities to meet regulatory and corporate goals and objectives, and to maintain the integrity of the operations under normal and abnormal conditions. The results are:
- Personnel are well trained and understand how to perform their tasks;
- Personnel hired for positions possess the ability to perform the work;
- Personnel are qualified and, where applicable, certified for their positions; and
- Employees understand their roles and responsibilities and correct operating procedures.
Further to ensuring those who work on behalf of the company do so in a way that is safe and protects the environment, the Element 5 document states that In the event a contract worker requires specific training to perform a task at or on behalf of the Company, and the required training is not provided by the contractor’s organization, the Company will arrange to have the contract employee(s) trained prior to beginning any work for the Company. To link this to the EM program, the PMPL EMP states All PMPL Programs align and adhere to Element 5 and the Element 5 framework to ensure resources are competent, qualified, have sufficient training and understanding to safely execute their roles in support of the PMPL assets and Program requirements while mitigating the risk of injury or performance loss.
The MPLL process for this audit protocol relies heavily on the training and competency of both staff and other persons who work with or on behalf of the company. While this aspect is important, it is not the only area that needs to be focussed on to reach compliance with this audit protocol. As the OPR paragraph states “[…] aware of their responsibilities in relation to the processes and procedures required by this section”, there is a need for some form of communications component to this process to ensure the necessary information about section 6 of the OPR is making its way to both employees and those working on behalf of the company.
MPLL’s ICP provides detailed roles and responsibilities for staff during an incident. This includes what specific role, such as Planning Section Chief or Incident Commander, each staff member will be assigned in the ICS structure if an incident is of a significant enough size that it is implemented. Each position in ICS has its roles and responsibilities carefully laid out for the incumbent to follow in the event a person is asked to fulfil a role in the ICS framework. Having detailed, pre-determined procedures for positions within the ICS structure allows for any potential responder to work in a consistent and effective manner. The MPLL EMP states The Company requires that all response personnel, including contractors and casual labour, have the appropriate training necessary to serve on a response team during an emergency.
MPLL referred to its Public Awareness Program (PAP) when asked how it communicates with the public, local first responders, and public officials. MPLL stated that it meets with these various groups along its right-of-way on a two-year schedule with additional information provided when necessary. To ensure all necessary information is either provided or discussed with these key stakeholders, a checklist was developed and is utilized during each meeting. Examples of these checklists was provided during the audit. These key stakeholders, and other response personnel, are provided MPLL training. In addition to the training, first responders, public officials from local communities, and government agencies are provided with access to interactive emergency response drills held by MPLL at various locations along its system should they wish to attend. Emergency exercise frequency is specified in the ICP and, from the records observed by the CER auditors, it is being maintained. The last exercise the CER was involved with was on 14 May 2025 and the scenario was a simulated release of oil into the Yamaska River. Activities involved boom deployment and decontamination of responders at a control point near the Chemin des Érables.
MPLL is taking steps to ensure both its employees and contractors, or those that work on behalf of the company, are well trained and competent in their roles, including EM specific roles that may take place during an incident.
AP-05 Internal and External Communications
Finding Status |
Non-compliant |
Regulation |
OPR |
Regulatory Reference |
Paragraph 6.5(1)(m) |
Regulatory Requirement |
A company shall, as part of its management system and the programs referred to in section 55, establish and implement a process for the internal and external communication of information relating to safety, security, and protection of the environment. |
Expected Outcome |
|
Relevant Information Provided by the Company |
The following key documents and records are related to this finding:
The following interviews are related to this finding:
|
Finding Summary |
In summary, MPLL does not have a communications process that addresses internal communication, which is mandatory and repeatable. By activity, MPLL has many of the aspects that would be expected of a communications process, however it relies on the actions and the memory of its well-trained and experienced staff to follow through on them. If these staff were to leave, it could create a knowledge gap that would allow mistakes to take place and the existing plans to fail. |
Detailed Assessment
MPLL pointed to Element 10.1 Recognize and Respond to Community Expectations document as the process to meet this audit protocol requirement. The document goes on to say The purpose of this System is to ensure effective management of stakeholder relationships to enhance the trust and confidence of the communities in which we operate and to ensure that all necessary actions are taken for the protection of the public, the environment, and Company personnel and assets. As part of identifying the audiences and the materials that will need to be communicated, the company has identified emergency response plans and procedures as something that fits with this requirement. The document states PMPL will ensure that programs and procedures are in place to address the community’s concerns about the company’s operations as related to safety, security, health and the environment, and emergency response plans and procedures. “Community” is defined as those residing near an operating terminal, a pipeline or pipeline facilities (valves, meters, etc.) to which the activity is easily detectable either visually, aurally, or by other means.
In discussion with MPLL staff, they pointed to various communication tools that are used with different external audiences. Landowners are provided with letters and calendars with the companies contact information and some basic information with respect to the pipeline and emergencies. First responders, such as fire and police departments, along the right-of-way are met with on a two-year cycle to update existing and new staff of the incident response plans that would be used should something occur in their jurisdictions. Examples of the checklists of additional information provided to first responders was provided to the CER auditors during the audit.
The PMPL Communications Manual provides a list of target audiences that may need to be contacted depending on the issue or event. One of the groups on this list of target audiences is employees. The document goes on to say Whether to communicate to each of these audiences and in what priority order will be determined based on the issue and event. However, it is important to always consider the various audiences affected by actions of PMPL.
MPLL pointed to Safe Work Permits, Field Level Hazard Assessments, employee training, and the ICP as some of the methods and activities used to communicate its messages internally. The ICP has both internal and external communication pieces built into it. The ICP contains several figures which outlines, in detail, the internal notification sequence to be followed should an incident take place. The figure provides details about the various roles that need to be notified, what each role is supposed to do, along with contact names and phone numbers to allow for quick notifications.
While MPLL was able to demonstrate that its external communication was performed by following a process, there is, however, little information on the process for internal communications. From a review of documentation and interviews with various MPLL staff, the CER auditors are of the opinion that MPLL has very knowledgeable, long-term staff that are performing internal communication activities, but it is by activity and not necessarily by following a documented process. The CER auditors are aware that a company cannot account for every scenario and activity that might require a communications plan, procedure, or work instruction. However, by not requiring staff to follow a repeatable process, it may create confusion if the who, what, when, where, why, and how are not properly accounted for in the development of a communications plan or for where a specific activity is about to take place.
MPLL provided a significant amount of EM-related documents to demonstrate how both external and internal communications are being carried out. The documents are distinct in the audience/stakeholder and message(s) conveyed to the end user. However, the majority of the internal communications appears to the CER auditors to be done by activity and not by a documented process as is required by the audit protocol.
AP-06 Document Management
Finding Status |
Non-compliant |
Regulation |
OPR |
Regulatory Reference |
Paragraph 6.5(1)(o) |
Regulatory Requirement |
The company shall, as part of its management system and the programs referred to in section 55, establish and implement a process for preparing, reviewing, revising, and controlling those documents, including a process for obtaining approval of the documents by the appropriate authority. |
Expected Outcome |
|
Relevant Information Provided by the Company |
The following key documents and records are related to this finding:
The following interviews are related to this finding:
|
Finding Summary |
In summary, MPLL does identify the ICP as a critical document and a key part of its documentation related to the overall EM program, and it is kept up to date. However, the process does not explicitly point to the authorizing person(s) who are allowed to provide sign off on all documentation. In addition, while the Element process requires the Element Champion to review and update the processes and procedures that make up each Element on a three-year cycle the CER auditors identified numerous documents where this is not being done. This is both a non-compliance to the OPR requirement and a non-conformance to MPLL’s internal documented requirements. |
Detailed Assessment
MPLL pointed to its Element 4 Information & Documentation document to address the process requirement for this audit protocol. The document states that this Element covers the storage, updating, and retention of drawings, manuals, documentation, and records pertaining to equipment, operations, maintenance, and inspection for active and abandoned facilities that may affect the safety, health, environment, reliability, or compliance of the Company. In MPLL’s EMP document, the linkage between the company’s EM program and Element 4 is shown in the following document quote: The scope of PMIMS Element 4 Information and Documentation is to enhance the safety, security, health, and environment of the PMPL assets through the storage, update and retention of drawings, manuals, documents, and records. All PMPL Programs align to Element 4 to ensure the associated documentation, records, applicable regulations, permits, codes, and drawings are available and accessible, protected from loss or theft, and the changes are communicated and documented.
MPLL’s process includes a requirement to develop, publish, and maintain an approved list of critical manuals. This includes the following requirements:
- Identification of documents to be managed;
- Maintenance of the documentation for currency, accuracy, accessibility, and protection;
- Protection of the documentation against loss including protection of information subject to client -solicitor privilege;
- Distribution and communication of the documentation to the appropriate personnel; and
- Filing system and retention of the documentation in accordance with regulatory and corporate requirements.
MPLL’s list of critical documentation is the following:
- Safety Data Sheets;
- Integrated Contingency Plan (EM related);
- Disaster Recovery Plan;
- Critical Operating and Maintenance Procedures;
- Relief system data sheets; and
- Engineering Drawing Management Program.
The CER auditors agree with MPLL that all of the above documents are critical in nature and fulfil important needs for the company. The ICP, which is listed above, is very important from an EM perspective and MPLL was able to demonstrate that this document was revised in accordance with the process. However, the CER auditors noted that management system documentation, including the processes and procedures required to implement and maintain MPLL’s existing management system, are not explicitly stated as being part of this list of critical documents for the company, and no other process was provided for these documents. As this is the process requirement pointed to by MPLL staff, the CER auditors expected it to contain, at a minimum, requirements about the ongoing implementation, continual improvement, and maintenance of the company’s management system documentation.
After reviewing MPLL’s process, the CER auditors did not identify where obtaining approval for the documents by the appropriate authority is to take place. While it could be inferred through the Responsibilities and Accountable Resources section of the document that this is taking place, it is not explicitly stated for any of the senior roles.
According to the Element 4 Information & Documentation document, the Element Champion is to revise the Element as required, or 3 years after the previous revisions/review. For this Element, the CER auditors did observe that the document was dated 1 June 2023, which in the CER auditor’s opinion is up to date. As it relates to EM documentation, MPLL was able to demonstrate that both the ICP and the PMPL EMP have been updated in the last three years. However, this was not the case for many of the other Element documents and their associated procedures reviewed by CER auditors. For example, MPLL indicated that various pieces of Element 6 were last updated between 2014 and 2019, and the entire Element 10 was last updated in 2014. Generally, unless the company provides a reasonable argument otherwise, the CER auditors expect management system process documentation to be reviewed regularly and updated on a re-occurring basis as required. This three-year period allows for a reasonable continual improvement cycle and aligns with the OPR requirement for audits of the protection programs
From an EM perspective, the ICP requires that the documenting of incident response actions begin at a very early stage in the incident response, and it also specifies what type of information needs to be recorded. According to the ICP, the Document Unit Leader is responsible for the maintenance of accurate, up-to-date incident files. This would include such documents as the Incident Action Plan, communication logs, and situation status reports to name a few. Following the ICS roles, each role, especially the roles with some level of authority, are required to complete a log of their actions and incident events using standardized ICS forms, in this case the 214-unit log form.
MPLL does identify the ICP as a critical document and a key part of its documentation related to the overall EM program, and it keeps the document up to date. However, MPLL has several gaps in its overall process to meet this audit protocol requirement. The process does not explicitly point to the authorizing person(s) who are allowed to provide sign off on all documentation, and the management system documentation is not considered a critical document according to the process steps for Element 4. In addition, while the Element documents require the Element Champion to review and update the processes and procedures that make up each Element on a three-year cycle the CER auditors identified numerous areas where this is not being done, and some documentation appears to be at least 10 years old without being updated. This is both a non-compliance to the OPR requirement and a non-conformance to MPLL’s internal documented requirements.
AP-07 Contingency Planning
Finding Status |
No issues identified |
Regulation |
OPR |
Regulatory Reference |
Paragraph 6.5(1)(t) |
Regulatory Requirement |
A company shall, as part of its management system and the programs referred to in section 55, establish and implement a process for developing contingency plans for abnormal events that may occur during construction, operation, maintenance, abandonment or emergency situations. |
Expected Outcome |
|
Relevant Information Provided by the Company |
The following key documents and records are related to this finding:
The following interviews are related to this finding:
|
Finding Summary |
In summary, through its detailed ICP, MPLL has demonstrated that it has developed and implemented the required processes and procedures to achieve the expected outcomes required of this OPR paragraph. |
Detailed Assessment
MPLL staff pointed to the Element 10 Community Awareness and the Emergency Preparedness documents to address the process requirement of this audit protocol. The Element states The purpose of this Element is to ensure compliance with all applicable regulations related to emergency preparedness and response. Emergency planning and preparedness are essential to ensure that all necessary actions are taken for the protection of the public, the environment, and Company personnel and assets. Within the process, the document states Emergency response plans include (to name a few):
- Specific risk and response scenarios;
- Emergency shutdown criteria;
- Internal and External notification procedures;
- PMPL Spill Management Team responsibilities and ICS roles for all hazards emergencies; and
- Communication procedures with local first responders (police or fire department) if evacuations of neighbouring premises are required.
The intended results of following Element 10 include:
- Effective emergency response plans and resources in place, and updated as required;
- Emergency preparedness is tested, with resources being assessed and upgraded, as required, on a regular basis;
- Community concerns are recognized, understood and appropriately recognized within Company preparedness plan; and
- Key community stakeholders and first responders have the opportunity to review Company response plans through Company distribution of ICP and periodic training opportunities.
MPLL’s ICP contains a significant number of documented potential scenarios, or plans, that it may encounter if an incident were to occur. Many of these detailed scenarios can be considered contingencies for both normal and abnormal operating conditions.
Emergency or contingency plans are tested by conducting simulations and drills as per Element 10.3 - Simulations and Drills. In May 2025, CER auditors attended an emergency exercise at a control point in Brigham, QC where MPLL carried out a boom deployment across the Yamaska River. A post-exercise analysis report was completed to identify areas of improvement and address gaps.
Through its detailed ICP, MPLL has demonstrated that it has developed, established, and implemented the required processes and procedures to achieve the expected outcomes required of this OPR paragraph.
Appendix 2: Terms and Abbreviations
For a set of general definitions applicable to all operational audits, please see Appendix I of the CER Management System Requirements and CER Management System Audit Guide found on www.cer-rec.gc.ca.
Term or Abbreviation |
Definition |
|---|---|
CSA |
Canadian Standards Association |
CER |
Canada Energy Regulator |
CER Act |
Canadian Energy Regulator Act (S.C. 2019, c.28, s.10) |
EMP |
Emergency Management Program |
HLRA |
Higher Level Risk Assessment |
ICP |
Integrated Contingency Plan |
ICS |
Incident Command System |
OPR |
Canadian Energy Regulator Onshore Pipeline Regulations (SOR/99-294) |
PAP |
Public Awareness Program |
PMIMS |
Portland Montreal Integrity Managing System |
PMPL |
Portland Montreal Pipe Line |
The company |
Montreal Pipe Line Limited |
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