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CONTRACTOR JOB SAFETY PLAN (CJSP)

Contractor Job Safety Plan

Project Name

TABLE OF CONTENTS
1.0 General Information..................................................................................................................................................................................................... 3
2.0 Project Tenets and Principles....................................................................................................................................................................................... 4
3.0 Job Scope Overview.................................................................................................................................................................................................... 5
2012 Chevron Pipe Line Company. All Rights Reserved. Page: 1 of 15 Reviewed: November 2012. Uncontrolled when printed.
CONTRACTOR JOB SAFETY PLAN (CJSP)

4.0 Risk Assessment and Hazard Identification................................................................................................................................................................. 6


5.0 Certification, Education and Training............................................................................................................................................................................ 8
6.0 Hazard Communication................................................................................................................................................................................................ 8
7.0 Personal Protective Equipment (PPE)......................................................................................................................................................................... 8
8.0 Environmental.............................................................................................................................................................................................................. 8
9.0 Managing Subcontractors............................................................................................................................................................................................ 8
10.0 Audits, Inspections, and Planned Observations........................................................................................................................................................... 8
11.0 Motor Vehicle Safety.................................................................................................................................................................................................... 8
12.0 Security Measures....................................................................................................................................................................................................... 8
13.0 Short Service Employee (SSE) Training and Identification.......................................................................................................................................... 8
14.0 Communication............................................................................................................................................................................................................ 8
15.0 Incident, Injury, and Illness Management..................................................................................................................................................................... 8
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1.0 General Information

Developed Chevron Pipe Line Date


for: Company :

Location: City: State


:

Job ID:

Job Description:

Name Telephone Cell Phone


CPL Contact
Contractor Foreman
Contractor Project Manager
Contractor Safety
Representative
Additional Contacts (if
applicable)
Subcontractors (if applicable)

2012 Chevron Pipe Line Company. All Rights Reserved. Page: 2 of 15 Reviewed: November 2012. Uncontrolled when printed.
CONTRACTOR JOB SAFETY PLAN (CJSP)

Third-Party Contacts (if


applicable)
Regulatory Agency Contacts
(if applicable)
Chevron Compliance Hotline This number is to be used to confidentially report Safety or
Environmental concerns which you feel have not been (800) 284-3015
addressed.
AXIOM Medical Consulting (877) 502-9466

2.0 Project Tenets and Principles

Stop Work Authority:


Every employee and contractor for Chevron is responsible and authorized to stop any work that does not comply with Chevrons tenets of
operations. There will be no repercussions for exercising Stop Work Authority; it is a right and a responsibility.

We Believe All Incidents Are Preventable:


Do it safely or not at all.
There is always time to do it right.
When in doubt, find out.

Always:
1. Operate within design or environmental limits.
2. Operate in a safe and controlled condition.
3. Ensure safety devices are in place and functioning.
4. Follow safe work practices and procedures.
5. Meet or exceed customers requirements.
6. Maintain integrity of dedicated systems.
7. Comply with all applicable rules and regulations.
8. Address abnormal conditions.
9. Follow written procedures for high risk or unusual situations.
10. Involve the right people in decisions that affect procedures and equipment.

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CONTRACTOR JOB SAFETY PLAN (CJSP)

3.0 Job Scope Overview


See instructions for an example of a typical project scope breakdown needed to accomplish an effective hazard analysis.
Job Scope:
Work Activity Task Description (subsequent JSA title) Location Company Major Equipment


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CONTRACTOR JOB SAFETY PLAN (CJSP)

4.0 Risk Assessment and Hazard Identification


See instructions for an example of a typical risk assessment of a Work Activity/Task Description.

Work Activity: Task Description (JSA Title):


Potential Hazards Mitigations

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CONTRACTOR JOB SAFETY PLAN (CJSP)

Gravity Temperature Hazard Controls (Engineering and Administrative)


Overhead work Ignition source Work Permits Ignition source controls Break Rotation
Falling object Hot/Cold surfaces PPE Program Gas monitoring Temporary Lighting
Excavation Hot/Cold liquids Warning signs Material Safety Data Sheets Isolation of Hazardous Energy
Collapsing roof/equipment Hot/Cold gases Pipeline markers Scaffolding Equipment Inspections
Elevated/Uneven work surface Hot/Cold weather conditions Spotters/Attendants Parking Plans Other:
Open holes Other: Barricades Equipment Staging Plans Other:
Other: Other: Housekeeping Essential personnel only Other:
Motion Chemical Safety Controls (Personal Protective Equipment)
Vehicle/Equipment movement Explosive/Flammable vapors
Hard hat Leather gloves Hearing protection
Limited mobility (confined Carcinogen Compound
Safety shoes Chemical gloves Fire Resistant Clothing
space) Toxic Compounds
Safety glasses Electrical rated gloves Other:
Material movement Corrosive Compound
Face shield Chemical suit Other:
Water/Wind movement Reactive Compounds
Goggles Work vest/Life vest
Body positioning/Ergonomics Pyro-phoric material
Cotton gloves Full body harness
Manual Lifting Other:
Other: Biological Safety Equipment
Mechanical Fire Extinguishers Personal Monitors Caution tape
Animals/Insects
Rotating equipment Bacteria/Viruses Fire retardant tarps Tag line Area Monitors
Compressed springs Blood Borne Pathogens Locks and tags Safety cable Other:
Drive belts and conveyors Contaminated food/water Gas detectors Safety Barricade Other:
Motors Other: Emergency/Contingency Plans Environmental Equipment
Power/Hand tools Other:
Spill Control Incident Reporting Procedure Absorbent pads
Other: Radiation Spill Contingency Plans Early Injury Management Containment pans
Electrical
Lighting Emergency Evacuation Plans Other: Other:
Power lines (above/below) Welding arc/flash
Energized equipment Certification Requirements Licensing Requirements
Sunlight
Static charges X-rays Certified Welder Qualified Gas tester Asbestos Abatement
Wiring NORM scale Qualified Crane Operator Confined Space Attendant Lead Abatement
Batteries Other: Qualified Rigger Fire Watch Other:
Other: Sound Qualified Signal Man Equipment Operator
Pressure Competent Person Other:
Equipment noise
Scaffolding Inspector
Piping Impact noise
Cylinders Venting noise Safe Work Practices
Vessels/Tanks Communication (SimOps) Safe Work Electrical Safe Work Isolation of Hazardous Energy
Hoses Communication (Language) Bypassing Critical Protection Excavation Simultaneous Operations
Other: Other: Confined Space Lifting and Rigging Working at Heights
Other: Diving Hot Work Other:

PLANNING HAZARD ANALYSIS


Hazard Mitigation

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CONTRACTOR JOB SAFETY PLAN (CJSP)

Work Activity: Task Description (JSA Title):


Potential Hazards Mitigations
Gravity Temperature Hazard Controls (Engineering and Administrative)
Overhead work Ignition source Work Permits Ignition source controls Break Rotation
Falling object Hot/Cold surfaces PPE Program Gas monitoring Temporary Lighting
Excavation Hot/Cold liquids Warning signs Material Safety Data Sheets Isolation of Hazardous Energy
Collapsing roof/equipment Hot/Cold gases Pipeline markers Scaffolding Equipment Inspections
Elevated/Uneven work surface Hot/Cold weather conditions Spotters/Attendants Parking Plans Other:
Open holes Other: Barricades Equipment Staging Plans Other:
Other: Other: Housekeeping Essential personnel only Other:
Motion Chemical Safety Controls (Personal Protective Equipment)
Vehicle/Equipment movement Explosive/Flammable vapors
Hard hat Leather gloves Hearing protection
Limited mobility (confined Carcinogen Compound
Safety shoes Chemical gloves Fire Resistant Clothing
space) Toxic Compounds
Safety glasses Electrical rated gloves Other:
Material movement Corrosive Compound
Face shield Chemical suit Other:
Water/Wind movement Reactive Compounds
Goggles Work vest/Life vest
Body positioning/Ergonomics Pyro-phoric material
Cotton gloves Full body harness
Manual Lifting Other:
Other: Biological Safety Equipment
Mechanical Fire Extinguishers Personal Monitors Caution tape
Animals/Insects
Rotating equipment Bacteria/Viruses Fire retardant tarps Tag line Area Monitors
Compressed springs Blood Borne Pathogens Locks and tags Safety cable Other:
Drive belts and conveyors Contaminated food/water Gas detectors Safety Barricade Other:
Motors Other: Emergency/Contingency Plans Environmental Equipment
Power/Hand tools Other:
Spill Control Incident Reporting Procedure Absorbent pads
Other: Radiation Spill Contingency Plans Early Injury Management Containment pans
Electrical
Lighting Emergency Evacuation Plans Other: Other:
Power lines (above/below) Welding arc/flash
Energized equipment Certification Requirements Licensing Requirements
Sunlight
Static charges X-rays Certified Welder Qualified Gas tester Asbestos Abatement
Wiring NORM scale Qualified Crane Operator Confined Space Attendant Lead Abatement
Batteries Other: Qualified Rigger Fire Watch Other:
Other: Sound Qualified Signal Man Equipment Operator
Pressure Competent Person Other:
Equipment noise
Scaffolding Inspector
Piping Impact noise
Cylinders Venting noise Safe Work Practices

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CONTRACTOR JOB SAFETY PLAN (CJSP)

Vessels/Tanks Communication (SimOps) Safe Work Electrical Safe Work Isolation of Hazardous Energy
Hoses Communication (Language) Bypassing Critical Protection Excavation Simultaneous Operations
Other: Other: Confined Space Lifting and Rigging Working at Heights
Other: Diving Hot Work Other:

PLANNING HAZARD ANALYSIS


Hazard Mitigation



Work Activity: Task Description (JSA Title):


Potential Hazards Mitigations
Gravity Temperature Hazard Controls (Engineering and Administrative)
Overhead work Ignition source Work Permits Ignition source controls Break Rotation
Falling object Hot/Cold surfaces PPE Program Gas monitoring Temporary Lighting
Excavation Hot/Cold liquids Warning signs Material Safety Data Sheets Isolation of Hazardous Energy
Collapsing roof/equipment Hot/Cold gases Pipeline markers Scaffolding Equipment Inspections
Elevated/Uneven work surface Hot/Cold weather conditions Spotters/Attendants Parking Plans Other:
Open holes Other: Barricades Equipment Staging Plans Other:
Other: Other: Housekeeping Essential personnel only Other:
Motion Chemical Safety Controls (Personal Protective Equipment)
Vehicle/Equipment movement Explosive/Flammable vapors
Hard hat Leather gloves Hearing protection
Limited mobility (confined Carcinogen Compound
Safety shoes Chemical gloves Fire Resistant Clothing
space) Toxic Compounds
Safety glasses Electrical rated gloves Other:
Material movement Corrosive Compound
Face shield Chemical suit Other:
Water/Wind movement Reactive Compounds
Goggles Work vest/Life vest
Body positioning/Ergonomics Pyro-phoric material
Cotton gloves Full body harness
Manual Lifting Other:
Other: Biological Safety Equipment
Mechanical Fire Extinguishers Personal Monitors Caution tape
Animals/Insects
Rotating equipment Bacteria/Viruses Fire retardant tarps Tag line Area Monitors
Compressed springs Blood Borne Pathogens Locks and tags Safety cable Other:
Drive belts and conveyors Contaminated food/water Gas detectors Safety Barricade Other:
Motors Other: Emergency/Contingency Plans Environmental Equipment
Power/Hand tools Other:
Spill Control Incident Reporting Procedure Absorbent pads
Other: Radiation Spill Contingency Plans Early Injury Management Containment pans
Electrical
Lighting Emergency Evacuation Plans Other: Other:
Power lines (above/below) Welding arc/flash
Certification Requirements Licensing Requirements

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CONTRACTOR JOB SAFETY PLAN (CJSP)

Energized equipment Sunlight Certified Welder Qualified Gas tester Asbestos Abatement
Static charges X-rays Qualified Crane Operator Confined Space Attendant Lead Abatement
Wiring NORM scale Qualified Rigger Fire Watch Other:
Batteries Other: Qualified Signal Man Equipment Operator
Other: Sound Competent Person Other:
Pressure Equipment noise Scaffolding Inspector
Piping Impact noise Safe Work Practices
Cylinders Venting noise Safe Work Electrical Safe Work Isolation of Hazardous Energy
Vessels/Tanks Communication (SimOps) Bypassing Critical Protection Excavation Simultaneous Operations
Hoses Communication (Language) Confined Space Lifting and Rigging Working at Heights
Other: Other: Diving Hot Work Other:
Other:

PLANNING HAZARD ANALYSIS


Hazard Mitigation



5.0 Certification, Education and Training

Description Description Description

Abrasive Blasting Hazard Identification and Awareness Safety Observation/Audit


Back Injury Prevention Hazardous Energy Lock-Out Scaffolding Safety
Basic New Employee Orientation Hazmat Training Signs and Barricades
Basic Principles of Safety (e.g. OELS) HAZWOPER Training Start-up Safety Workshop
Behavior Based Safety Hearing Conservation Program Water Survival
Benzene, Asbestos, Lead, and H2S Awareness Heat and Cold Stress Prevention Welding/Cutting
Bloodborne Pathogens Helicopter Safety Other
Body Positioning Training Hot Taps Other
Commercial Diving Hot Work Other
Confined Space Entry Incident Investigation and Reporting
Cranes and Material Handling Industrial Hygiene Exposure Monitoring
Defensive Driving/Driving Safety Job Safety Analysis

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CONTRACTOR JOB SAFETY PLAN (CJSP)

Electrical Lock-Out/Tag-Out Land Transportation Safety


Electrical Safety Lifeboat Safety
Emergency Evacuation (Drills, Muster Points) Line Breaking/Opening Process
Emergency Marine Evacuation Marine Drilling Safety
Emergency Response Plan Near Miss Reporting
Excavation and Trenching Offshore Diving
Explosives and Ordinance Personal Protective Equipment
Fall Protection Power Actuated Tools
Fire Safety Radiation Control
Fire Watch Respiratory Control
First Aid (CPR, EMS) Respiratory Protection Program
Flammable and Toxic Material Handling Roofing Work Procedure
Floor and Wall Opening Safety Culture/Commitment Training
Hazard Communication (MSDS), Labeling, etc. Safety Equipment Usage

6.0 Hazard Communication


Chemicals Brought on Site
(By generic use name. List here or append a separate Chemical Inventory List.)
1.
2.
3.
4.
5.

Special PPE or Handling Requirements

7.0 Personal Protective Equipment (PPE)

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CONTRACTOR JOB SAFETY PLAN (CJSP)

Known Activities that Avenue of Exposure Personal Protective Equipment


Hazard Potential Source
potential contain Inhalation Skin/Eye Ingestion Other [Add relevant PPE to mitigate hazard]

Ammonia Nitrate

-Valve/Pump
Packing -Gaskets
-Pipe -Brakes Operations and
Asbestos Coating Maintenance
-Building
-Pipe Materials
-Insulation

-Sampling
-Tank
-Crudes -Spill Clean Cleaning
up
-Products -Tank
Benzene -Checking Inspections
-Solvents
Leaks
-Condensates -Waste
-Confined Handling
Space
Rescue or Emergency
Bloodborne Pathogens Contact with blood
Activities

-Welding
Burns -Hot Equipment Welding and Maintenance
-Sunlight
-Vehicle Emissions
Operations and
Carbon Monoxide -Fire Combustion
Maintenance
-Product

-Pipe Coating Material,


Coal Tar Mastic Maintenance
Herbicides, and Pesticides
-Weather
Operations, Maintenance,
Cold -Nitrogen Trucks
Line Purging
-Refrigeration units

Drag Reducing Agents

-Weather -Old
buildings Operations and
Dust -Abrasive Maintenance
blasting -Vaults

-Pipeline Coating Operations and


Epoxy Resins Maintenance, Pipeline
-Sealants Repairs

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CONTRACTOR JOB SAFETY PLAN (CJSP)

Known Activities that Avenue of Exposure Personal Protective Equipment


Hazard Potential Source
potential contain Inhalation Skin/Eye Ingestion Other [Add relevant PPE to mitigate hazard]

-Over head hazards


-Scaffolding Operations and
Falling Object Maintenance, Pipeline
-Construction zones Repairs
-Cranes

Operations and
Fiberglass Insulation
Maintenance, Repairs
Operations and
Repairs,Grinding on
Grinding Dusts Maintenance, Pipeline
equipment, fabrication
Repairs

Operations and
H2S Crude Oil, Oil fields
Maintenance
-Environmental -Furnaces
-Offices Operations and
-Switch Gear
Heat Maintenance, Pipeline
-Engines -Hot Crude Repairs
-Steam lines Lines

Operations and
Hydrocarbon Liquid Crude Oil, Oil fields Maintenance, Pipeline
Repairs
Operations and
Hydrocarbon Vapors Crude Oil, Oil fields Maintenance, Pipeline
Repairs

Operations and
LPG Facilities, pipelines,
L.P.G. Maintenance, Pipeline
tankers
Repairs
Engines, pumps, rotating Operations and
Lube Oils equipment Maintenance

ROW clearing
Lyme Disease Ticks
Job Walks in high brush
-Light Crude Oil, Oil fields, Pipeline repairs, Operations
Mercury and Maintenance
-Switches

Pipeline repairs, Operations


Metal Fumes Welding rods
and Maintenance

Noise (> 85 dBA) -Engines -Abrasive Pipeline repairs, Operations


blasting and Maintenance
-Pumps
-PRVs
-Compressors

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CONTRACTOR JOB SAFETY PLAN (CJSP)

Known Activities that Avenue of Exposure Personal Protective Equipment


Hazard Potential Source
potential contain Inhalation Skin/Eye Ingestion Other [Add relevant PPE to mitigate hazard]

-Hand Tools
Heavy
equipment

Pipeline repairs, Operations


N.O.R.M. Scale inside pipelines
and Maintenance

-Confined Spaces Pipeline repairs, Operations


Oxygen (lack of) and Maintenance
-Inert Atmospheres
Pipeline repairs, Operations
Paint Dust (lead) Old Buildings and pipelines
and Maintenance

Pipeline repairs, Operations


PCBs Transformers
and Maintenance
Pipeline repairs, Operations
Pollen Vegetation
and Maintenance

Operations and
Sewage lines, treatment
Sewage Maintenance, pipeline
facilities
repairs and installs
Operations and
Equipment, tools, broken
Sharps Maintenance, pipeline
glass, pipeline, etc
repairs and installs

Operations and
Abrasive blasting, mud
Silica/sand Maintenance, pipeline
mixing on drills, excavations
repairs and installs
Operations and
Maintenance, pipeline
Snake Bites Snakes
repairs and installs, ROW
clearings

-Lab chemicals
Operations and
Solvents -Degreasers Maintenance, pipeline
repairs and installs
-Paints

-Gulf of Mexico Operations and


Water Maintenance, pipeline
-Rivers, Stream repairs and installs

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CONTRACTOR JOB SAFETY PLAN (CJSP)

8.0 Environmental
Wastes Generated:

Waste Management Procedure:

Environmental Permit Compliance:

Spill Prevention and Containment:

Sensitive Area Protection:

9.0 Managing Subcontractors

10.0 Audits, Inspections, and Planned Observations

11.0 Motor Vehicle Safety

12.0 Security Measures

13.0 Short Service Employee (SSE) Training and Identification

14.0 Communication

15.0 Incident, Injury, and Illness Management

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CONTRACTOR JOB SAFETY PLAN (CJSP)

First Aid/Minor Treatment Facility (Clinic or other treatment center) Phone

Contact (Doctor or professional medical providers name) Phone

Emergency Medical Treatment Facility (Local Hospital/Regional Trauma Center) Phone

Emergency Transportation Provider (Attach driving route to this plan) Phone

Medical Management Plan Provider Contact Phone

Local Law Enforcement Phone

Local Fire Department Phone

Alternate Medical Management Plan Provider Phone


AXIOM Medical Consulting 877-502-9466
Incident Response:

HAZWOPER Emergency Plan: (Refer to instructions for requirements. This section should be discussed in detail. Append additional documents as
appropriate.)

Incident Reporting and Investigation: (Describe requirements and process)

2012 Chevron Pipe Line Company. All Rights Reserved. Page: 15 of 15 Reviewed: November 2012. Uncontrolled when printed.