Review of Events Associated with the Keefer Regulator Sewer … · Review of Events Associated with...

Mike Price & Associates Inc.

Review of Events Associated with the Keefer Regulator Sewer Overflow:

August 2006 to May 2008

June 25, 200

Review of Events Associated with the Keefer Regulator Sewer Overflow: August 2006 to May 2008

Mike Price & Associates Inc. i

Table of Contents

1. Introduction .............................................................................................................................1 1.1 General ........................................................................................................................................ 1 1.2 Understanding ............................................................................................................................. 1

1.2.1 Directions from City Manager..................................................................................................... 1 1.2.2 Work plan, budget and timeline .................................................................................................. 2

2. Methodology ............................................................................................................................3 2.1 Interviews ................................................................................................................................... 3

2.1.1 Staff Interviewed ......................................................................................................................... 3 3. Preliminary Findings ..............................................................................................................5

3.1 Timetable of events..................................................................................................................... 5 3.2 Areas of non-compliance .......................................................................................................... 11

3.2.1 Compliance with legislation ...................................................................................................... 11 3.2.2 Compliance with Procedure F-5-5 ............................................................................................. 11 3.2.3 Operator Certification and the Ottawa Wastewater Collection System ..................................... 12 3.2.4 Compliance with MOE District requirements ........................................................................... 14 3.2.5 Compliance with internal procedures ........................................................................................ 15

3.3 General findings ....................................................................................................................... 15 4.3.1 Related to the O&M of Keefer regulator ................................................................................... 15 4.3.2 Incident reporting ...................................................................................................................... 18 4.3.3 Addressing risks at the front line ............................................................................................... 19

4. Conclusions ............................................................................................................................20 4.1 Reason for overflow event occurrence ..................................................................................... 20 4.2 Reason for event discovery, by some, in the Spring 2007 ........................................................ 20 4.3 Reason for connection with beach postings in 2008 ................................................................. 21 4.4 Areas of non-compliance .......................................................................................................... 22

4.4.1 The owner or owner’s representative, ....................................................................................... 22 4.4.2 The front line management, ....................................................................................................... 23

4.5 Areas for improvement ............................................................................................................. 23 5. Recommendations .................................................................................................................25

5.1 Recommendations .................................................................................................................... 25 5.2 Next steps ................................................................................................................................. 26

Appendix A ...................................................................................................................................27 SAMPLE BRIEFING NOTE .............................................................................................................. 27 Lead in the drinking water. ................................................................................................................. 27

Issue / Background .................................................................................................................................. 27 Key Points ............................................................................................................................................... 27 Questions and Answers ........................................................................................................................... 28

Appendix B ...................................................................................................................................29 Incident reporting protocols for field incidents ................................................................................... 29

Level 1 Incident ....................................................................................................................................... 29 Level 2 Incident ....................................................................................................................................... 29 Level 3 Incident ....................................................................................................................................... 29

Appendix C ...................................................................................................................................30



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Appendix D ...................................................................................................................................31


Mike Price & Associates Inc. 1

1. Introduction 1.1 General The purpose of this study was to undertake a review as directed by the City Manager regarding events surrounding a malfunction of a CSO regulator that allowed sanitary sewage to be discharged into the Ottawa River for a period of approximately 15 days in August 2006. It was anticipated that up to 30 interviews of City staff might be needed and then a report generated for the City Manager. The deliverables in the report would address the following:

1. a timetable of key events in the whole process 2. a timeline of what transpired to cause the incident, and the steps taken afterwards to

rectify the situation 3. key notes from every interview 4. my personal observations and conclusions 5. a list of incidents where there was non-compliance with legislation, regulations, by-laws

or standard operating procedures 6. a review of implications within and external to the Public Works Department (morale,

reputation, lawsuits and charges pending) 7. key recommendations for remedial action, communication and training to mitigate further

mishaps

1.2 Understanding

1.2.1 Directions from City Manager Council has directed the City Manager to conduct a thorough review of the August 2006 sewer overflow at the Keefer regulator and report back to Committee and Council. The City Manager anticipated bringing a staff report forward for consideration by the Planning and Environment Committee and Council in July and August of 2008.

Specifically the review was to:

• Read all readily available and relevant information relating to the event in August 2006 and subsequent events up to and including May 2008 are to be reviewed.

• Interview staff associated with the events between August 2006 and May 2008.

• Identify recommendations for consideration and/or implementation to prevent a re-occurrence of the incident.

• Prepare a draft report that is to be completed by Friday June 20th 2008 and discussed with senior staff.

• Deliver the Final report on or before June 27, 2008.



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1.2.2 Work plan, budget and timeline I arrived in Ottawa on Sunday June 8th 2008 and, after being briefed by the City Manager and Deputy City Manager of Public Works & Services on Monday June 9th 2008, prepared the following work plan and timeline document which was submitted to Steve Box in the City Manager’s Office later that day. The list of people to interview was reviewed and set at around 20. Given the number of interviews the following plan was identified.

Phase Function Estimated Number of

Days I.

Planning • Develop and confirm work plan • Meet and be briefed by key senior management June 9, 2008

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II. Interviews of Staff • Plan the questions and arrange for interviews • List all the required reference data • Carry out interviews personally

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III. Analysis of Operating Protocols and Procedures • Material being requested of interviewees • Review material for inconsistencies • Draw conclusions and draft recommendations • Identify gaps and non-compliance

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IV Background Research • Review possible legislation that impacts on CSO’s • Identify any areas for improvement

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V. Interim Report • Prepare draft interim report due before June 20th • Verbally present findings to City Manager and/or Deputy City Manager on

or before June 13th

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VI. Final Report/Presentation • Final report due on or before June 27th • To retain all notes from interviews

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Total Number of days 8



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2. Methodology 2.1 Interviews Material that was supplied by the Director of WSB was extremely useful in determining the job functions of the various members of staff and what their roles may or may not have been in the incident.

This material and copies of e-mails, memos and reports provided the background for me to generate a list of questions for each interviewee.

2.1.1 Staff Interviewed • Aaron Burry Director Parks and Recreation

• Gerald Taylor Supervisor Sewer Inspections, WSD

• Luc Dugal Section Manager Sewer maintenance

• Barrie King Program Manager Waste Water Collection

• Dave McCartney Manager Wastewater and Drainage Services

• Felice Petti Manager Strategic & Environmental Services

• Dixon Weir Director Water & Wastewater Services Branch

• Curtis Rampersad Program Manager Infrastructure Assessment, Water Resources

• Eric Tousignant Senior Engineer Water Resources

• Louis Julien Senior Engineer Water Resources

• Krista Kreling Analyst Environmental Health, Public Health

• Wayne Newell Director Infrastructure Services

• Jean-Guy Albert Program Manager Inspections, Public Health

• Dr David Salisbury Former MOH Public Health

• Richard Hewitt DCM Public Works & Services

• Alain Gonthier Manager Infrastructure Management

• Isra Levy Acting MOH Public Health

• Ken Brothers Former Director PW&S

• Chris Melanson Operator level II Sewer Inspections

• Steve Burns District Manager MOE Ottawa Office



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Where requested by an employee, staff from Labour Relations, the Union or the Association was in attendance.

Steve Burns of the Ministry of Environment had Investigator Clint King from the MOE-EIB in the room with him during the conference call.



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3. Preliminary Findings 3.1 Timetable of events

Date EVENT COMMENTS July 31st 2006

Rainfall event started

August 1st 2006

Keefer Regulator activated automatically to allow overflows of combined sewage into Ottawa River via John Street overflow pipe.

Normal occurrence in heavy rainfall. System was designed to operate this way.

Early August 2006

Regulator failed to return to pre-storm condition allowing flows to continue overflowing into River and not passing through the Sewage Treatment Plant.

Blockage of a regulator or the outflow pipe due to debris is not uncommon. At this point the flow is not a CSO but an overflow of sanitary sewage (SSO) and reportable to MOE as a spill.

After August 4th or 5th

Impacts of storm passed by but the drop pipe outlet remains completely plugged with debris. Gate is stuck in closed position. Raw sanitary sewage is now passing through the overflow directly into the river.

Pre-amalgamation this regulator was maintained by the Region and it had monitors and alarms directed to an on-call supervisor’s pager. Post-amalgamation the alarm system was no longer available. Pre-amalgamation Region staff would routinely check the key regulators after a major storm event. Post amalgamation the staff shortage meant no post storm checks were routinely carried out

Aug 15th 2006

Staff technician in WSB was routinely downloading flow data remotely from the John Street overflow pipe in question. Noticed an anomaly and went to the site to verify that there was flow in the pipe even though there was no recent rain event.

Contacted his Supervisor in operations and cc’d three other Supervisors by e-mail at 2.27pm on August 15th and advised that there was flow in the overflow pipe even though no rainfall. Operations supervisor dispatched a crew to the site who used high



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pressure water hose to clear debris. Gate returned to normal position and bypass of raw sanitary sewage ceased. Crew returned to yard after end of day shift and filed the completed work order. The field staff and especially their Supervisor failed to comprehend the magnitude of the event and to differentiate between a normal overflow during a storm event and an extended sanitary spill in dry weather. The event should have been reported to MOE spills action centre at this point in time.

Mid-August 2006

Ottawa Public Health recorded very elevated E. coli counts at the Petrie Island Beach and posted the beach as unsafe for swimming throughout the period that the spill was occurring. They did not know why the counts remained so high after the rainfall event had long passed. The matter generated considerable media attention.

The total overflow event lasted approximately 15 days and the SSO flow rate was estimated to be 50,000 cubic metres per day. The sewer-shed is very large and this sanitary sewage flow might have been between 5% and 10% of the normal dry weather flow at the sewage treatment plant. No-one had connected the beach postings to the continuing spill.

Nov 7th 2006

At meeting with MOE staff they request that Ottawa start reporting annually on the CSO overflows.

The MOE had issued letters to all municipalities on April 26th 2006 asking for reporting regarding compliance with F-5-5. MOE first started request to Region in 1996. Letter to Manager WSB on May 18th 2006 asking for data on certain events. Meeting with Ottawa staff June 27th 2006 where data on CSO flows requested.



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Mid-March 2007 April 23rd 2007 (3pm) April 25th 2007 May 1st 2007

Senior Engineer in ISB is preparing data to go in the first annual CSO report to the MOE. He is reviewing data from 2006 and sees a discrepancy between a modeled overflow of a few hours and real overflow of hundreds of hours in duration. He contacts Operations and receives confirmation of closed regulator that was cleared on Aug 15th 2006. Time coincides with end of flows. He contacts the WSB Manager and his ISB Program Manager by e-mail and advises them of the issue and that he mentioned this event to MOE staff during a discussion on another matter. Advised MOE that the whole event would be documented in the upcoming 2006 annual report on CSOs. He sends draft CSO report/letter to WSB Manager for his review and transmittal to MOE. He supplies the estimated magnitude of the overflow and numerous other relevant details to his ISB Program Manager and the WSB Manager.

MOE District Manager is given brief overview of conversation between his engineer and the Ottawa engineer regarding the gate being stuck in early August 2006. In the e-mail dated May 01, 2007 the Engineer clearly states to the Manager WSB and his Program Manager in ISB that ‘…this incident was never officially reported to MOE …’

May 2nd 2007 May 16th 2007 May 23rd 2007

WSB Manager directed his Program Manager by e-mail to prepare a report to MOE describing the event in 2006. This would be done independently of the CSO report. Letter is sent to Bryan Dickman of MOE regarding the malfunction of the Keefer regulator. Stated in letter that ‘incident never formally reported to MOE.’ Copied only to Manager WSB and the Senior Engineer ISB. First Annual Report on CSOs for 2006 is issued to MOE.

Letter is sent to MOE with very limited circulation internally within the City. Given the magnitude of the spill, plus the fact that the ISB Engineer was unable to substantiate that the spill had ever been reported to MOE, the issue should have been elevated to the Director and the DCM. Staff could not provide any clear direction, or protocol, for issues management within the Department.



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Mid-February 2008

Senior Engineer in ISB is preparing Part B of Report on Combined Sewer Area Pollution Prevention and Control Plans. Wanted to see if there was any correlation between beach postings and CSOs. Obtained data from PH and found correlation not only for CSO events, but for the August 2006 SSO event. He also mentions this connection in casual conversation to fellow employee who is a member of the Fallingbrook Community Association, which encompasses Petrie Island beach.

He advised his program manager of the connection. This information never moved anywhere else in the organization. The connection between spill and beach postings is mentioned in public meeting of Fallingbrook Community Association on March 25th 2008. Minutes were distributed on April 19th 2008.

April 2nd 2008

Senior Engineer reads about PH report on beaches in the press. Calls PH analyst to explain his findings regarding the possible correlation to overflows and even the SSO event. He advises his supervisor in ISB. He sends e-mail to PH. Director of WW is cc’d on an e-mail from the Senior Engineer to the WSB management staff and indirectly made aware of link between overflows and beach postings. Manager WSB told his Program Manager to add PH to the Spills reporting protocol.

PH analyst advises her Program Manager immediately. He immediately writes an e-mail to the MOH explaining the possible connection of spill to Petrie Island beach postings. The information was never circulated within the PW&S Department and never reached the DCM level.

April 3rd 2008

MOH and Director of WW are at Committee during the discussion on the PH 2007 beach report.

At this point both have been e-mailed the very preliminary information their respective staff have, regarding the possible connection between overflows and beach postings at Petrie Island.



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April 23rd 2008

PH report on beaches 2007 went to Council.

MOH announces his departure from City of Ottawa right after the Council meeting.

May 5th 2008

Manager WSB advises verbally the Manager SES of connection between the beach postings and SSO event.

May 7th 2008

Manager WSB takes local politicians on tour of ROPEC. Mentions the likely connection between regulator gate malfunction and the Petrie Island beach postings.

Staff of Parks & Recreation is present at the tour and this is first time P&R are made aware of any of the events. Staff person calls Director of P&R immediately.

May 13th 2008

DCM first becomes aware of whole issue while his Director WSB was heading to a meeting with East End Councillors regarding Petrie Island beach. Intent of meeting was to brief Clrs and prepare for press conference and timing of the release of the information.

DCM asks Director WSB for more information and is briefed over following week as information becomes available.

May 15th 2008

Director WSB receives more detailed information from ISB staff regarding possible correlation of beach postings to regulator malfunction.

May 20th 2008

Local politician holds press conference to announce that the beach postings in August 2006 were now explainable.

May 20th 2008

DCM issues statement to Council to explain event in 2006 and mentions it was reported to MOE at that time.

Based on discussion between the Manager WSB and the responsible Supervisor the assumption was that the incident had been reported. (The Senior Engineer in ISB, back on May 1st 2007, had advised this WSB Manager by e-mail that he could not substantiate any reporting to MOE.)



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May 22nd 2008

DCM issues sequence of events memo to Council regarding the event and still assumes spill had been reported to MOE.

Director WSB still believed staff had reported incident to MOE in 2006.

May 27th 2008

DCM issues new statement to Council retracting the mention of reporting the spill to MOE when it occurred in August 2006.

The key Supervisor, during an interview with Director WSB on May 26th, retracted his statement regarding reporting the August 2006 event to the MOE - SAC.

May 28th 2008

Key Supervisor terminated as a result of internal review.

Assignment of ORO designation to staff person holding Level IV Certification.



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3.2 Areas of non-compliance

3.2.1 Compliance with legislation There are numerous pieces of legislation that apply to the Public Works and Services Department.

Specifically governing the actions of the Corporation and staff associated with the regulator incident the following appear to have some relevance.

1. Ontario Water Resources Act. Regulates water pollution, approvals of sewage facilities, licensing of sewage works operators.

2. Safe Drinking Water Act. Accreditation of the operating authority, QMS standards.

3. Environmental Protection Act. Part X, Regulation of spills.

4. Lakes and Rivers Improvement Act. Discharge of contaminant into rivers.

5. Federal Fisheries Act. Discharge of deleterious substance into water frequented by fish.

6. Ontario Conservation Authorities Act. Similar requirements to Federal Fisheries Act.

7. Canadian Environmental Protection Act. Report releases of contaminants to water.

8. Corporate due diligence and exercising ‘all reasonable care’ by establishing a proper system and taking reasonable steps to ensure effective operation of the system.

9. MOE policy document for controlling CSO’s known as procedure F-5-5

3.2.2 Compliance with Procedure F-5-5 Procedure F-5-5 is a supporting document for Guideline F-5, Levels of Treatment for Municipal and Private Sewage Treatment Works Discharging to Surface Waters. The Procedure applies to sewage treatment works with combined sewer systems such as in Ottawa. (A combined system is a wastewater collection system which conveys sanitary sewage and storm water runoff in a single pipe, called a combined sewer, to a sewage treatment plant.) There are three goals of Procedure F-5-5: a. Eliminate the occurrence of dry weather overflows b. Minimize the potential for impacts on human health and aquatic life resulting from Combined Sewer Overflows (CSO) c. Achieve as a minimum, compliance with body contact recreational water quality objectives (Provincial Water Quality Objectives, PWQO) for Escherichia coli (E. coli) at beaches impacted by CSOs for at least 95% of the four-month period (June 1 to September 30) for an average year. The requirement governing Ottawa’s wastewater collection system requires that,



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1. during a seven month period commencing within 15 days of April 1st, capture and treat for an average year all the dry weather flow plus 90% of the volume resulting from wet weather that is above the dry weather flow,

2. compliance with body contact recreational water quality objectives at beaches impacted by CSOs for at least 95% of the four-month period (June 1 to September 30) for an average year and, most importantly,

3. eliminate the occurrence of dry weather overflows (this occurred as a result of the gate malfunction)

This procedure applies to CSO events however, once the regulator malfunctioned the flow would be considered a spill of sanitary sewage and is reportable to the MOE Spills Action Centre immediately upon discovery. This was not done.

3.2.3 Operator Certification and the Ottawa Wastewater Collection System The operator certification program became a mandatory program in 1994 with the coming into effect of O. Reg. 435/93, made under the Ontario Water Resources Act. Drinking and wastewater operators have been governed under O. Reg. 435/93 until the coming into effect of O. Reg. 129/04 on August 1, 2004. Thus since August 2004, and during the events under review, the City has needed to be in conformity with Ontario Regulation 129/04. 3.2.3.1 Owners responsibility

Owners have been assigned specific responsibilities under O. Reg. 129/04 as listed below. Responsibilities

• File an application for facility classification or reclassification • Ensure the certificate of facility classification is displayed in workplace • Ensure that every operator who directs work on the facility holds a licence applicable to

that facility, or a conditional licence • Ensure that a copy of the licence of every operator in their employ is displayed at the

workplace of the operator, or if this is not practical, then at the premises from which the workplace is managed

• Designate an overall responsible operator (ORO); notify Director if relying on section 15 (2) (‘back-up’ ORO) for 60 days in any 12 month period

• Designate one or more operators as operators-in-charge (OIC) • Ensure that records are maintained of the amount of time each operator works as an

operator-in-charge • Ensure that logs or other record-keeping mechanisms are provided to record information

concerning the operation of the facility; authorize persons to make entries in log or other record keeping mechanism

• Ensure that logs and other record-keeping methods are accessible in the facility for at least 2 years after each entry in it is made



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• Ensure that operators and maintenance personnel have ready access to operations and maintenance manuals that contain plans, drawings, and process descriptions sufficient for the safe and efficient operation of the facility

• Ensure that the manuals are reviewed and updated at least once every two years • Ensure that every operator employed in their facility is given 40 hours of training each

year • Keep records of the training operators receive, containing specific information, and

submit copies of summaries to the Director when requested to do so.

There is a requirement to have a Licensed Operator designated as the overall responsible operator (ORO) as well as the shift operator in charge (OIC) for Wastewater Collection Systems.

There has been no written record given, regarding the assignment an ORO to the operational supervisors or the wastewater collection and drainage staff since amalgamation. The Supervisors assumed that the Program Manager was the ORO. The Program Manager is a P Eng, registered in BC, has an operator license of a level below that of the system, and as such he cannot be the permanent ORO. (A Professional Engineers, accredited in Ontario, would not have to meet the experience qualifications if they obtain an 85% pass on the exam for a level IV operator.)

The Program Manager stated that the shift schedule was the designation vehicle and the senior official (supervisor) on call was the OIC. This shift schedule has been in place since 2002.

None of the material produced for me identifies who was holding what designation at the time of the incident.

3.2.3.2 Classification of the wastewater collection system

Sewage works are to be operated by persons holding a valid operator’s licence of the same type as the type of facility. At least one operator must hold a licence of the same class or a higher class than the class of the facility. Thus a first step in deciding what certificate an operator should hold is to have the facility classified. Sewage works are divided into two types of facilities in the Regulation 129/04, the first is a wastewater collection facility. A wastewater collection facility means a sewage works that collects or transmits sewage but does not treat or dispose of sewage. Based on the classification of the system an operator designated must hold the required certification. I was advised that Ottawa is a Level IV system and therefore a Level IV operator has to be designated. Since amalgamation it is not clear whether anyone has been officially designated and clearly told that they are the overall responsible operator of the collection system.

On May 28th 2008 the only Level IV supervisor in the wastewater unit was verbally advised by the Division Manager that he was now considered the ORO.



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3.2.3.3 Record keeping for operation of system

The operator-in-charge or a person authorized by the operator-in-charge must record the following information on each operating shift:

• the date, the time of day the shift began and ended, and the number or designation of the shift

• names of all operators on duty during the shift • any departures from normal operating procedures that occurred during the shift, and the

time they occurred • any special instructions that were given during the shift to depart from normal operating

procedures, and the person who gave the instructions • any unusual or abnormal conditions that were observed in the facility during the shift,

any action that was taken and any conclusions that were drawn from the observations; and

• any equipment that was taken out of service or ceased to operate during the shift, and any action taken to maintain or repair equipment during the shift.

The owner must ensure that all logs and other record-keeping methods are accessible at the facility for at least two years after each entry in it was made. Nobody interviewed supplied me with any hand written documentation. Only copies of electronic e-mails or completion notes on the City’s Work Order system appear to be the records kept.

3.2.4 Compliance with MOE District requirements Staff at the Manger level and below was unaware of exactly when the Ministry of Environment District staff had requested reporting on CSOs into the overflow pipes and thus the Ottawa River. The staff thought that, at a November 2006 meeting, MOE first requested an annual report on the CSOs be supplied to them.

The MOE District Manager stated that the first written requests for CSO data started with the Region back in 1996. On April 27th 2006 a letter went from the Ministry to all Ontario municipalities stating that they wanted storm event combined sewer overflows to be brought into compliance with procedure F-5-5.

On May 18th 2006 a letter from the MOE was sent to the Manager of WSB requesting field data on certain CSO events

At a meeting on June 27th 2006 the MOE staff requested data on all CSOs and STP by-passes. . They were suggesting, volume, duration, location and wastewater characteristics (BOD, TSS, e-coli) for each event and each location, which would have been onerous to say the least. They agreed to accept a report based on modelling and flow simulation rather than 100% field measurements.

The letter of May 16th 2007 from the Program Manager to the MOE engineer regarding the regulator malfunction did not refer to the event other than ‘overflow’. The event was considered



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by MOE staff to be a spill of sanitary sewage and complete disclosure and reporting was required as soon as it was discovered. This was not fully complied with.

The May 23rd 2007 report submitted by Ottawa, for CSO overflows for the year 2006, was received by the MOE on May 25th 2007.

The MOE inspects the Ottawa sewage treatment plant annually but has not yet started inspections on any municipal sewage collection systems. The municipality is responsible for compliance with all regulations.

They feel the City of Ottawa is moving towards compliance with Procedure F-5-5 through its Real Time Control Plan and the Pollution Control Plan.

3.2.5 Compliance with internal procedures Operations staff has internal procedures that identify who is to be contacted in the event of a spill into the environment. The internal procedures have not been incorporated into a City of Ottawa Standard Operating Procedure. While internal procedures have not been harmonized since amalgamation, they do exist in some form or another. Yet, the internal procedures were not followed in a comprehensive manner, as nobody contacted anyone outside their own immediate unit or Division.

3.3 General findings Numerous non-regulatory issues were discovered during the interviews. They have been grouped into various categories and known best practices identified where applicable.

3.3.1 Related to the O&M of Keefer regulator 3.3.1.1 Alarms

Pre-amalgamation, the regulator, known as the Keefer regulator, was operated and maintained by the Region of Ottawa-Carleton. As designed, it was equipped with monitors and alarms that would register with the pager of the on-call operator. While the system was cumbersome it worked and the operators knew when the gate was moving. However, the alarms would go off numerous times as the flows fluctuated during the storm.

Post amalgamation, when the regional staff combined with the new City of Ottawa organization the monitors and alarms were not operating. Initially at amalgamation the Operations staff was combined first and Maintenance staff of the Region sometime later. When staff from the Regional Maintenance was combined with the Ottawa staff, the alarm pagers were not working. As a result they were not available in August 2006 and no alarm was raised. Nobody can adequately explain the reason for the alarm discontinuance.

Post event in 2008, the staff is planning to quickly install flow monitors and alarms in the overflow pipes to detect flow should the regulator malfunction again. This is an appropriate best practice.



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3.3.1.2 Post storm inspections

Pre-amalgamation the regulators were routinely checked after major storm events as it was not uncommon to have debris partially blocking the gate. However the chamber is deep and requires 4 members on the work crew due to the requirement for Confined Space Entry safety procedures.

Post amalgamation the staff shortage in the wastewater O&M section led the front line managers to eliminate this level of service. Consequently the jammed gate was not detected as quickly as it might have been pre-amalgamation even without the alarms.

The front line management staff allocating the severely limited resources post amalgamation was not addressing risk as part of their decision making process. The risks to the corporation need to be factored into decisions that are made around service level cuts. Thus cutting back on debris clearing activities at storm inlets may have contributed to the debris that blocked the regulator gate.

3.3.1.3 Regular maintenance inspections

The regular maintenance inspection pre-amalgamation was done once per month and after significant rainfall events. The maintenance is still done monthly but had been reduced to what the program Manager considers ‘a minimum’ as the regulators will be replaced when the Real Time Control project (RTC) is put into effect in approximately 18 months. The regular maintenance work was usually done the last week of the month. It is likely the spill event would have gone on until the end of August without the intervention by the staff person downloading flow data from a monitor.

The need for an adequate and regular inspection would have been identified at the time of the design of the regulator and should have been incorporated into the manuals and SOP’s needed by the maintenance staff.

The lack of current SOPs for the regulator is now clearly an urgent matter as the newly assigned ORO (as of May 28th 2008) did not operate the regional collection system pre-amalgamation and is in need of clear and concise O&M procedures. Now that the regulator maintenance has been reduced to ‘a minimum’ the risk of other mechanical malfunctions, such as chain breakage and rust friction on the float mechanism, has risen. This needs to be addressed as to whether it is an acceptable risk.

3.3.1.4 Knowledge of regulator purpose and design

The O&M for the regulators was supervised by the same person who looked after them in the Region. I was unable to interview him as he was terminated at the end of May. However I do have notes from his interview with the Division Director. Over the course of his 35 year career with the Region and City he only recalls 10 similar events when the gate was stuck.

The current Program Manager has no idea what the regulator is designed to do, nor why it is needed.

The owner is required to ensure that operators and maintenance personnel have ready access to comprehensive operations and maintenance manuals that contain the plans, drawings and process descriptions necessary for the safe and efficient operation of the facility.



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There was no indication of SOP’s or manuals being available to any staff interviewed relating to the Keefer regulator. It was felt that the former supervisor knew what the regulator was designed to do and that any flow in the overflow pipe after the storm event had passed had to be sanitary sewage and therefore reportable by him to the MOE as a spill of SSO.

I am not sure anyone else charged with the day to day operation of the collection system truly understands the exact role of the regulator and therefore when conditions change from CSO to SSO. Several people saw the volumes reported in the year 2007, identified as an overflow in August 2006, and compared to volumes of CSO were not surprised at the total volume. What is disconcerting is that several front line staff did not initially recognise this as an SSO event and therefore a spill.

The crew dispatched to the regulator, when the flow was detected in the overflow pipe, went out on an inspection Work Order. They had to use high pressure hoses to clear the debris blocking the gate. They do not keep any logs or diaries but record the work done on the Work Order form and file it upon their return. Similarly the Supervisors do not keep records, diaries or log-books. They rely extensively on e-mails and the check-off boxes on the Work orders.

The record of the stuck gate was not clearly flagged for the Supervisor to read the next day. He failed to note the magnitude of the malfunction and no communication was undertaken with anyone else.

3.3.1.5 Flow monitoring downstream

There is a flow monitor downstream of the Keefer regulator that records depth of flow against time, in the overflow pipe. It is one of the more reliable monitors and uses ultra-sound to measure depth. Occasionally the data would be spiked or erratic and needed to be verified before entering into the City’s database. The Technician started in his role as a monitoring operator with the Region in Dec 1998, just prior to amalgamation. The depth of flow and time data from this monitor is usually downloaded remotely and the data entered into the Department’s database for future analysis. This data is used to calculate the volume of CSO flow by-passing the sewage treatment plant and going directly into the river.

The technician, who was downloading the data remotely, saw that two weeks after the storm event there was some flow in the overflow pipe. He was concerned that his computer was reading erroneously so visited the site to verify flow. If he had backed up the depth of flow and time data for many days he might have been able to surmise the flow had been constant for two weeks. He had no need to do this at that time for his assigned work and did not think to analyse why or how long the regulator had been malfunctioning. By going to the site and seeing and hearing flow he would not know volumes. The monitor would show depth and he would only have assumed an issue with the gate at that point in time. When he had verified flow he advised his direct supervisor then later sent an e-mail to the key supervisor responsible for the regulator plus cc’d his supervisor and the third supervisor in the wastewater collection section advising them of flow and that there must be a problem with the regulator gate that needs rectifying. He heard back from his supervisor a short while later that the regulator had been returned to normal working condition.

When he worked for the Region the monitors were alarmed to the supervisor pagers. They did not function well and often hundreds of events were going to the pagers at all hours of the day



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and night. He recalls he learnt that the alarms and pager system were not operational from his supervisor, sometime in 02/03.

This level II operator keeps a record of key incidents in a personal diary. He is not aware of any direction or requirement for staff to keep log-books or diaries.

3.3.2 Incident reporting 3.3.2.1 Field crews and front line supervisors

It appears that the crews and especially the front line supervisors (the OICs) are not using diaries or log-books to record key events. There is too much reliance on Work Order form checking plus e-mails. Both of which can be easily lost. The inter-office e-mail traffic is increasing to the point where many are considered junk and never read. For some the e-mail is considered as the CYA vehicle. Whether it is read and digested is immaterial as the sender can say ‘I told you’.

As stated earlier this is not in conformance with Ont. Reg. 129/04.

3.3.2.2 Issue briefing notes

There appears to be a lack of any formal internal process that informs all staff when and how to advise senior management on critical issues. There does appear to be some form of ‘no surprises’ protocol that starts at the Manager level and goes up to the DCM level but this protocol is not widely known or used. If a written document did exist then staff training could have been focussed on internal communication skills.

Briefing notes on items would be useful to senior management on issues coming before Council, on issues that may become a risk to the Corporation and on incidents that may become media items. An example would have been the determination of correlation between the SSO event and the beach postings. A briefing note to the Director would have assisted when dealing with the PH report at Committee (and Council) as well as when meeting with the local Councillors regarding the Petrie Island Beach postings.

The Director of the Section, back in August 2006, was similarly totally unaware of any incident related to the regulator malfunction. The key information was held below the Director level and within two branches of the Department.

A sample of an internal Briefing Note (Related to drinking water) is attached as Appendix A

3.3.2.3 Incident reporting protocols

There has been a lack of awareness of the need to advise or report within the Department. While staff is relied upon to deal with most situations there is a requirement that senior management be advised of key issues or critical incidents. There is a ‘No surprises’ protocol in Public Works and Services that only exists at the Manager, Director and DCM level, but nobody below this level is aware of it. Often there are risks to the Corporation or information known only by senior staff that can impact the situation but if they are not advised, they cannot take action.



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For field staff this incident reporting is even more important and some guidance is required to explain who needs to tell whom and under what conditions. If all the front line staff and supervisors had informed the senior staff at key stages in this event then the situation would not have got out of hand and put the Corporation at legislative, financial and reputation risk.

A sample incident reporting protocol is attached as Appendix B.

3.3.2.4 Communications within the Department

There did not appear to be a clear communication protocol in place in 2006 for internal communications within the various divisions and departments. There is a need to move the right information up, down and across the organisation to the correct person(s). Thus when reporting incidents to another Department, such as from PW&S to PH, it needs to be determined, at what level in the organisation ( or to which person) does the information go initially and ensure that the information will be distributed to the correct people who need to know in order to take action.

Similarly for serious incidents, the reporting should be person to person live and not through any electronic messaging. Thus when information of an important nature has to be relayed late on a Friday evening, and acted upon immediately, it must go into a Department to the correct person and be moved throughout that unit to all the necessary people.

Clear lines of communication need to be identified and incorporated into the department’s revised protocols and Standard Operating Procedures. The Spills Event Protocol is the prime example that needs updating.

3.3.3 Addressing risks at the front line Typically, as a result of amalgamation of many small municipal public works functions there is imbalance of staff in the new structure. While the small municipalities had staff multi-tasking, the larger ones, like the Region, had dedicated staff. The Transportation function tends to get the resources it needs as first priority. As a consequence, the sewer O&M unit ends up with insufficient staff for the required level of service expected. Compound the problem by the wish to cut staff in the early years and you have a high risk of something going wrong.

The sewer maintenance section found itself in this predicament. At amalgamation, (2000), they lost 18 FTE’s. Then in 2002 they were directed to cut 15 FTE’s (17 actually went) and had to make some serious cuts in levels of service supplied in order to manage with the 26 field staff remaining from pre-amalgamation to post amalgamation. These cuts were made in their best judgement but did not address risks and consequences. The Manager was advised by the Program Manager of the cuts by a copy of a memo dated March 26th 2003. One area that is very labour intensive is grille cleaning of debris. If the grilles and bar screens are not cleaned there is risk of flooding at the storm inlet. Also, debris gets swept into the sewer system causing problems elsewhere and possibly at the regulators in the combined sewer area.

Ideally the WSB should initiate some form of Risk Management Model that can be easily understood and used by the Wastewater staff. A conceptual outline is attached as Appendix C.



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4. Conclusions 4.1 Reason for overflow event occurrence The overflow of sanitary sewage into the Ottawa River for +/- 15 days, as a result of the Keefer regulator malfunction, occurred physically due to debris clogging the regulator outlet and preventing the gate from operating as designed and returning to its normal operating position.

The change from a CSO to a SSO event went unnoticed for two weeks due to a number of checks and balances NOT being in place. Many of these did exist pre-amalgamation when the Region was responsible for the regulator. They are listed below.

1. The field crew did not flag the malfunction as a major incident or even spill for their Supervisor.

2. The Supervisor failed to note the completed Work Order as a spill event and therefore a reportable incident.

3. There was no designated ORO or OIC (or back-up) at time of the event.

4. The spills protocol had not been updated to reflect the new City organization.

5. The alarm system on the overflow pipe flow monitor was inoperable.

6. No SOP’s or manuals for the maintenance of the regulators.

7. Below minimal FTE’s assigned to sewer maintenance activities with resulting reduced levels of service and higher risks.

8. The field staff did not have an SOP for an inspection of the regulator after a major storm event.

9. The monthly maintenance on the regulator and its mechanical parts was down to an absolute minimum due to its pending replacement in 18 months.

10. There was no internal incident protocol to require reporting vertically up the staff levels within the Department.

4.2 Reason for event discovery, by some, in the Spring 2007 In the Spring of 2007 staff were preparing the first annual report for the MOE on the volumes of Combined Sewer Overflow’s for 2006 when it was noticed that the CSO event of early August continued well beyond the end of the rainstorm. The volume of total flow was estimated and only made available to a limited number of staff. Those copied on the May CSO report were the same ones directly involved with the findings, namely the Manager WSB, and Senior Engineer in ISB. The overflow event was reported to the MOE at the same time as the CSO report was sent in May 2007. At this time there was no connection made between the SSO event and the high bacteria count, with resultant beach postings, at Petrie Island Beach.



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Given the magnitude and duration of the SSO there should have been a wider circulation of the CSO report and SSO letter that went to the MOE in May 2007. Possibly the connection to the beach postings would have been made a year earlier than it was and saved Ottawa Public Health Department the resource allocation, time and money spent on the beach pollution investigations.

The lack of circulation was not done deliberately to hide the data, especially as it was given to the MOE and is therefore considered in the public domain. The reason is more due to lack of clear reporting protocols which can be summarised as follows.

1. Lack of clear and written internal departmental incident reporting protocols for field staff.

2. Lack of well documented ‘need to know’ procedures, such as briefing notes, for internal communication.

3. Lack of any clear communication protocols to advise other Departments of appropriate events.

4. Staff think functionally in silos and only concerned with events that directly impact them or their work.

5. Staff still working and thinking along lines of communication based on their former municipality prior to amalgamation.

6. Staff have not been trained in legislation compliance procedures nor clearly told their authorities and responsibilities regarding any and all legislation impacting their work.

7. No clear and written reminders to professional and MOE certified staff that they are accountable for their actions, or lack of action, under pertinent legislation.

8. Nobody responsible departmentally for quality assurance in regard to compliance with current legislation associated with the O&M of the complete wastewater collection system.

4.3 Reason for connection with beach postings in 2008 In the Spring of 2008 the Public Health Department prepared a report to Committee on the Petrie Island beach postings and the results of their investigations into the cause of the high bacteria counts in 2006. At the same time Public Works staff was trying to model a connection between CSO events and beach postings. They did see a correlation with the CSOs and also felt there was an extremely good correlation between the very high bacteria counts at Petrie Island beach and the regulator malfunction in August 2006.

As a result of the information from the PH report appearing in the newspapers staff from Public Works realised that the connection had not been communicated to those who really needed to know. At this time a staff person in Public Works contacted a staff person in Public Health with the pertinent information.

The same conclusion regarding communication protocols applies here as for the section above.

(a) Lack of clear and written internal departmental incident reporting protocols for staff.



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(b) Lack of well documented ‘need to know’ procedures, such as briefing notes, for internal communication.

(c) Lack of any clear communication protocols to advise other Departments of appropriate events.

(d) Lack of regular meetings with staff in other Departments who have similar issues or work in common areas.

(e) Staff aligned functionally in silos and only concerned with events that directly impact them or their work.

(f) Staff have not been trained in legislation compliance procedures nor clearly told their authorities and responsibilities regarding any and all legislation impacting their work.

(g) No clear and written reminders to professional and MOE certified staff that they are accountable for their actions, or lack of action, under pertinent legislation.

4.4 Areas of non-compliance While many pieces of Ontario legislation apply to the Ottawa wastewater collection system the following are the key areas where the Corporation as the ‘Owner’ or the staff as the ‘operator’ failed to meet their responsibilities.

4.4.1 The owner or owner’s representative, 1. Did not ensure the certificate of facility classification for the collection system was

clearly displayed in the workplace 2. Did not ensure that every operator dealing with the regulator (a Class IV facility) holds a

licence applicable to that facility, or a conditional licence 3. Did not clearly designate an overall responsible operator (ORO) 4. Did not clearly designate one or more operators as operators-in-charge (OIC) 5. Did not ensure that records are maintained of the amount of time each operator works as

an operator-in-charge 6. Did not ensure that logs or other record-keeping mechanisms are provided to record

information concerning the operation of the regulator; authorize persons to make entries in log or other record keeping mechanism

7. Did not ensure that logs and other record-keeping methods are accessible in the facility for at least 2 years after each entry in it is made

8. Did not ensure that operators and maintenance personnel have ready access to operations and maintenance manuals that contain plans, drawings, and process descriptions sufficient for the safe and efficient operation of the facility

9. Did not ensure that the manuals are reviewed and updated at least once every two years 10. Did not ensure in 2006 (at time of event) that every operator employed in their facility is

given 40 hours of training each year 11. Did not, in 2006, keep records of the training that the operators receive.



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4.4.2 The front line management, The management below the level of Director have the requirement to follow the legislation as it pertains to the ORO and OIC duties.

While an ORO had not been designated there was an informal understanding of the role of an OIC.

Specifically the OIC is authorized to:

• set operational parameters for the system or for a process that controls the effectiveness or efficiency of the system; and

• direct or instruct operators in the system. In August 2006 the operator-in-charge, or shift operator, or a person authorized by the operator-in-charge failed to:

1. take all steps reasonably necessary to operate the processes within his responsibility in a safe and efficient manner, in accordance with the relevant operations manuals

2. ensure that the processes within his responsibility were measured, monitored, sampled and tested in a manner that permitted them to be adjusted when necessary

3. ensure that records were maintained of all adjustments made to the processes within his responsibility, and

4. ensure that all equipment used in the processes within his responsibility was properly monitored, inspected and evaluated and that records of equipment operating status were prepared and available at the end of every operating shift.

The operator-in-charge or a person authorized by the operator-in-charge failed to record the following information on each operating shift: 5. the date, the time of day the shift began and ended, and the number or designation of the

shift 6. names of all operators on duty during the shift 7. any departures from normal operating procedures that occurred during the shift, and the

time they occurred 8. any special instructions that were given during the shift to depart from normal operating

procedures, and the person who gave the instructions 9. any unusual or abnormal conditions that were observed in the system during the shift, any

action that was taken and any conclusions that were drawn from the observations; and 10. any equipment that was taken out of service or ceased to operate during the shift, and any

action taken to maintain or repair equipment during the shift.

4.5 Areas for improvement The Wastewater Operator Certification Program certifies operators of wastewater systems as having met professional standards related to education, annual training, experience, and knowledge. These professional standards ensure that these systems are operated by knowledgeable and experienced operators.



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The operator certification program began as a voluntary program in 1986/87 introduced by the MOE, the Municipal Engineers Association, and Metropolitan Toronto. The voluntary program was intended as a bridge to allow time to work out the details of a mandatory program in consultation with stakeholders, including professional organizations and bargaining units. The operator certification program became a mandatory program in 1994 with the coming into effect of O. Reg. 435/93, made under the Ontario Water Resources Act. Wastewater operators have been governed under O. Reg. 435/93 until the coming into effect of O. Reg. 129/04 on August 1, 2004. There is a need to ensure that Ottawa’s staff are trained on and meet all the requirements of the pertinent Regulations applicable to the wastewater collection system. The Ontario Acts and Regulations can be viewed and downloaded at www.e-laws.gov.on.ca The Federal Acts and Regulations can be viewed and downloaded at www.laws.justice.qc.ca/en



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5. Recommendations 5.1 Recommendations While there are many areas that need to be addressed as a result of this review I believe the following are the key ones arising from my investigation.

1. There is a requirement to have an MOE certified Operator clearly designated, and documented, as the overall responsible operator (ORO) as well as the shift operator in charge (OIC) for Wastewater Collection Systems.

2. The operator-in-charge or a person authorized by the operator-in-charge must record the required information on each operating shift.

3. The owner must ensure that all logs and other record-keeping methods are accessible at

the facility for at least two years after each entry in it was made. 4. Internal procedures need to be harmonized (since amalgamation).

5. The internal procedures need to be incorporated into Standard Operating Procedures.

6. The City should quickly complete the installation of flow monitors and alarms in the overflow pipes to detect flow should the regulator malfunction again.

7. The required inspection protocol for the regulator would have been identified at the time of the design of the regulator and should be incorporated into the maintenance manuals.

8. The City shall ensure that operators and maintenance personnel have ready access to comprehensive operations and maintenance manuals that contain the plans, drawings and process descriptions necessary for the safe and efficient operation of the regulator.

9. The front line supervisors (especially the OICs) should start using diaries or log-books to

record key events.

10. The use of internal briefing notes to senior management on critical issues needs to be initiated.

11. An incident reporting protocol for field staff needs to be established and some guidance is

required to explain who needs to tell whom and under what conditions. 12. Clear lines of communication need to be identified and incorporated into the

department’s revised protocols and Standard Operating Procedures.

13. The Public Works and Services Department should initiate some form of Risk Management Model that can be easily understood and used by the Wastewater staff.

14. There is a need to ensure that the wastewater staff is trained on and meet all the requirements of the pertinent Regulations applicable to the wastewater collection system.



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15. The corporation needs to be able to demonstrate that due diligence has been put in place by establishing a proper system to prevent an offence occurring and by taking all reasonable steps to ensure the effective operation of the system. A sample check list of steps is included in Appendix D.

5.2 Next steps The City needs to undertake work to address the recommendations contained in this review.

The key areas to complete first are recommendations #1 to #5 inclusive that pertain to compliance with legislation.

Recommendation #6 is already underway.

Recommendations #6 to #12 can be initiated right away for completion in a timely manner and will be part of the future ‘due diligence’ undertaking.

Ideally recommendations #12 to #15 inclusive can be coordinated at a Corporate level and possibly led by the City Manager’s Office. The suggested steps for implementing recommendation #15 is included in Appendix D.



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Appendix A SAMPLE BRIEFING NOTE

Lead in the drinking water.

Issue / Background The staff in the City of ABC has been testing the lead levels in the City’s water pipes on a regular basis and found the levels to be risings in certain parts of the City. The lead levels are not dangerous and the ABC drinking water consistently meets or exceeds all provincial drinking water standards. Lead seldom occurs naturally in water supplies such as lake, river or well. Lead enters the drinking water as a result of corrosion or wearing away of materials containing lead found in the service pipes or household plumbing. ABC has XX,000 lead service pipes and has a replacement program to eventually eliminate all lead from the City owned pipes. However, unless the homeowner or building manager replaces the material within the private property then the risk still remains for lead to be in the tap water. The lead pipes, and lead solder, were originally used as a pipe material before the health concerns were fully understood. The pipes are found predominately in the older parts of the city bounded by Street A, Street B, Street C and Street D. Health Canada has established a maximum acceptable concentration (MAC) of lead in drinking water of 10ppb (parts per billion) in a free flowing sample of water. In general the tap water in ABC tests out below 1ppb however a few samples in the area mentioned above have reached x ppb. City staff is undertaking further testing and a remedial plan will be prepared to reduce the risk of any potential health hazard. As part of its Customer Service program, the City will analyze water lead content at a customer’s tap upon request. Test results with lead levels above the Ontario standard and Federal Guidelines is an indication of the effect of the building’s plumbing.. The building plumbing falls under the Provincial Plumbing Code and not the Safe Drinking Water Act and therefore the Water Distribution Department has no jurisdiction. The City will be reviewing its lead service replacement program in order to see if an accelerated rate of replacement can be introduced in the capital budget.

Key Points 1. The quality of the drinking water at the sources for the City of ABC is better than Health

Canada Standards. However, the quality can decline if the water sits too long in a system containing lead plumbing.



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2. Lead based solder for copper pipes is prohibited in today’s Plumbing Code. Lead solder was used in buildings constructed prior to the late 1980’s. Buildings constructed prior to 1955 often contain lead service pipes from the City water main to the building.

3. Other sources of lead in the water within a house include faucets made of brass and

chrome plated brass.

4. To limit the exposure to lead the following steps can be taken: a. Remove standing water in the pipes each morning by first flushing the toilet,

washing your hands, or let the tap run for five minutes before drinking or consuming any water straight from the tap.

b. Use cold water for drinking, cooking or preparing baby formula as hot water dissolves more lead from the lead plumbing.

5. The City of ABC is committed to provide its customers with high quality, safe and clean

drinking water.

Questions and Answers How can customers get rid of the lead plumbing on their property? By How many lead service pipes are there in the City of ABC? There are XX,000 Is the City regularly conducting tests for lead? Yes, in certain areas of known lead service pipes. Is there a public education program for lead in drinking water? Not at the present time however we are working on one. What plans are in place for testing water in schools? Currently Are there devices that can be installed on the tap? Yes, but Prepared by: Mike Price 613-111-0000 Contact for detailed information: Wendy Doe 613-333-2222 Date: June 20, 2008



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Appendix B Incident reporting protocols for field incidents

Level 1 Incident • situation which can be handled entirely by the Staff on shift, with or without use of a

specialized contractor • event stabilized and actions taken to resolve situation (and prevent reoccurrence, if

possible) • Supervisor to advise Program Manager personally of situation

Examples include – response to operational alarms, first aid incident, Dept of Labour site visit, suspect sewer back-up,

Level 2 Incident • event which requires immediate notification of others, as per Incident Protocols

Database/SOP • event stabilized but further resources needed to bring situation under control • Manager to be advised personally of situation • Manager in consultation with corporate Communications staff to decide if wider

communication is needed • Manager to advise Director personally

Examples include – sewer blockage which affects many and/or critical customers, injury to staff, spill to environment,

Level 3 Incident • event not under control and actual or potential situation likely to require significant

resources beyond normal O&M operations • event needs to be planned and/or directed from head office • situation may involve other groups such as emergency responders, Public Health, MOE

and even the City’s Emergency Planning Office • Deputy City Manager must be apprised of situation immediately and personally • Deputy City Manager in consultation with Communications staff to decide next steps in

communications process • Communication strategies and tactics such as news releases, briefing notes, development

of key messages and co-ordination of media interviews to be done by Communications staff.

• Communications command central to be established on site of situation, if possible

Examples include – major force main break which impacts very large number of customers, major ROW impacts that will last more than 8 hours, breach of security, loss of life, potential for major environmental damage.



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Appendix C A concept approach to Risk Management for front line management staff would be:-

• To provide the background and rationale for undertaking an enterprise risk management program.

• To provide a framework for implementing a comprehensive enterprise risk management program in the City of Ottawa Wastewater Division, and specifically the storm and sanitary sewer collection system.

• To provide the tools for the wastewater unit to expand the process and move towards Continuous Improvement plus a financial risk management.

• To incorporate the outcomes into new SOP’s Getting started could be as easy as a workshop environment.

Conduct a two or three full day workshop with a cross section of staff, ideally including other key Departments as appropriate, to,

i. define risk for the staff involved ii. review the risk assessment model – what are enterprise risk management ERM

concepts and methodologies iii. identify the business objectives iv. review each business objective and define the risk tolerance levels v. prepare an initial list of questions to stimulate discussion on risks

vi. take a first cut at a preliminary risk profile or create the ‘top ten risks’ vii. identify how the ERM model can lead to a Financial Risk Management model

viii. identify how this approach can assist in setting budget priorities for the unit and identifying where the resources should be allocated (to the top risks)



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Appendix D The corporation needs to demonstrate that due diligence is in place by establishing a proper system to prevent an offence occurring and by taking all reasonable steps to ensure the effective operation of the system.

The key elements of a proper system can be summarised as follows;

1. a corporate environmental policy approved by Ottawa Council

2. a corporate compliance system covering the management structure, responsibilities, training, resources, compliance reviews and reporting relationships

3. clear and repeated communication of the policy and system to the employees

4. ensure appropriate levels of resources for the Service Levels established along with the budget to support it

5. training and retraining of staff with record keeping

6. use of outside expertise where appropriate

7. regular internal and external reporting

8. proper and clear communication systems

9. periodic compliance reviews

10. outside audits where appropriate

11. continual review of legislation and changes

12. basic staff training in legal requirements and compliance

13. regular maintenance and replacement of equipment

14. adequate alarms systems including regular testing

15. written records by staff regarding compliance

16. good working and cooperative relationship with District MOE staff

Individual staff members need to ensure personal due diligence by following the following simple steps.

(a) Carry out duties in competent manner according to their job description and instructions from immediate supervisor

(b) Be aware of and comply with procedures regarding notification protocols with respect to discharges of deleterious material into the natural environment

(c) Review operations manuals and contingency plans to stay up to date with changes



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(d) Bring issues or potential problems to the attention of supervisors promptly as per internal incident protocols

(e) Ensure they receive the proper training and document it

Document the important things that they do, say or are told to do, in a log book or personal diary

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