6. Each mitigation was verified and individually documented

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1 CHESM/MSW Field Verification Instructions: All information in sections A, B and C must be completed. Information in section B related to subcontractors should be obtained from the work crew if possible. If info is unavailable, leave blank. In section C, only items applicable to the work being performed must be completed. For example, if you are observing a confined space entry job, you will complete items Confined Space Entry, IHE and Portable Gas Detection at a minimum. General Information A. Person Conducting Verification Name: CAI: B. Verification Information Engagement Location: Date of Engagement: Specific Location: Time of Day (Day/Night): Workforce Type (check): Employee Crew Contractor Crew Mixed Crew Is the Work Crew a subcontractor of a primary contractor (check): Name of Primary Contractor: If applicable, name of Subcontractor: Check all specialized activity that was being conducted during the verification: Confined Space Diving Electrical Excavation Hot Work IHE Lifting and Rigging Portable Gas Detection Verification Questions C. Behavior - Check '' or '' for each item listed. If document reason. Job Safety Analysis (JSA): The task scope was discussed and documented in the following detail: 1. All steps associated with the work task were identified and documented. Hazards & Mitigations were identified, discussed and documented in the following detail: 2. Hazards associated with each task step were documented. 3. Each mitigation was documented. 4. Hazards & mitigations were identified based on consequence potential (i.e. with the potential to cause serious injury or fatality death) and documented. 5. Hazards & mitigations identified were appropriate for the work task. Mitigations were completed and documented in the following detail: 6. Each mitigation was verified and individually documented on the JSA prior to starting work. Stop work authority was discussed and documented in the following details: 7. Stop work situations were discussed with the work crew. Human Performance was discussed and documented in the following details: 8. Workers are knowledgeable and confident to conduct the work? 9. Actions to take if conditions change or unplanned events occur. (e.g. stop and seek assistance) Short Service Employee Management: 1. Did work crew contain SSEs? (If no, skip question 2-7) 2. Was a SSE Risk Reduction Plan in place? (If yes skip question 3-7) 3. SSEs were visibly identifiable. 4A. Was crew size less than 5 workers? (If no, skip question 4B) Control of Static Electricity Work at Height Other: 1

2 4B. Crew does not contain more than 1 SSE or is working under approved variance. 5A. Was crew size in excess of 5 workers? (If no, skip 5B) 5B. Crew does not contain more than 20% SSEs or is working under an approved variance. 6. SSEs were assigned mentors. 7. Mentors were on site. Emergency Management: Work crews were: 1. Knowledgeable about facility alarms and muster points. 2. Able to explain emergency evacuation procedures. Permit to Work: Work was permitted in accordance with Chevron permitting 1. Permits were authorized by a qualified Permit Approver. 2. The task scope was defined on the work permit (and on any specialty permits/certificates). 3. The work conditions under which the permit is valid were discussed and understood by the work crew. 4. A competent individual was designated responsibility to monitor and verify work is performed safely and is consistent with the permit conditions. D. Supplemental Items Complete ONLY items applicable to the work being performed during verification. Confined Space Work: Confined space work was conducted in accordance with Chevron 1. Entry to the confined space was controlled at all times by an entry attendant who was aware of rescue responsibilities and entry logs were maintained. 2. Initial gas testing was conducted & documented in 3. Gas monitoring was conducted & documented in 4. All permits were documented and kept at the worksite. 5A. Did the confined space contain special hazardous characteristics? (If no, skip question 5B & 5C) 5B. Rescue teams and equipment were readily available. 5C. Rescue plans were documented and communicated to the work crew. Commercial Diving Work: Commercial diving work was conducted in accordance with Chevron 1. A dedicated dive supervisor, working diver, stand-by diver, tender for the working diver and tender for the stand-by diver were onsite at a minimum. 2. All diving equipment was inspected prior to use; inspections were documented. 3. Rescue plans were developed, documented and communicated to the work crew. 4. Conditions under which the dive must be terminated were documented and discussed with the work crew. 5. The diving was conducted in accordance with the special permit/certificate conditions. 6. All permits were documented and kept at the worksite. 2

3 Electrical Work: Electrical work was conducted in accordance with Chevron 1. Electrical systems, power lines, equipment and parts were verified to be in an electrically safe work condition prior to starting work. (e.g. de-energized, isolated, etc.). 2. Access to the electrical work area was restricted and safe work zones were visibly identifiable. 3. Grounding was in place to prevent feed-backs on equipment (e.g switchgear, motors, etc.). 4. Electrical work was conducted in accordance with all permit conditions. 5. All permits and hazard analyses (e.g. shock & arc flash, JSA, etc.) were documented and kept at the worksite. 6A. Was electrical work conducted inside the limited approach boundary? (If no, skip question 6B & 6C) 6B. Only qualified electrical personnel worked inside the limited approach boundary. 6C. A qualified electrical stand-by person was onsite. 7A. Was electrical work conducted on or around overhead power lines? (If no, skip question 7B) 7B. Equipment (including mobile equipment) maintained minimum clearance distances from overhead power lines. Excavation: Excavation work was conducted in accordance with Chevron 1. Excavation area is barricaded to prevent unauthorized access by vehicles and personnel. 2. All underground conduits, electrical cables, etc. within the limits of the excavation have been isolated. 3. All permits were documented and kept at the worksite. 4A. Were protective systems required for this excavation? (If no, skip question 4B) 4B. The excavation and adjacent areas and all protective systems were inspected daily (and if conditions changed); inspections were documented. 5A. Was gas testing required for this excavation? (if no skip question 5B) 5B. Gas testing was conducted & documented on the permits. 6A. Was the excavation classified as a confined space (Excavations over 4 feet limited access and egress should be considered as confined spaces)? (if no, skip question 6B & 6C) 6B. Rescue teams and equipment were readily available. 6C. Rescue plans were documented and communicated to the work crew Hot Work Hot work was conducted in accordance with Chevron 1. Hot work was conducted in accordance with the special permit/certificate conditions (if not conducted in a designated safe hot work area) 2. Initial gas testing was conducted & documented in 3. Gas monitoring was conducted & results were documented in accordance with the qualified gas tester s specification. 4. A dedicated fire watch was onsite to monitor work conditions. 3

4 5. Access to the hot work area was controlled and visible barriers/warning displays were erected. 6. Dedicated fire-fighting equipment (e.g. fire extinguishers, hoses, etc.) was onsite and available for immediate response. 7. All permits were documented and kept at the worksite. Isolation of Hazardous Energy: Potentially hazardous energy (including electrical, mechanical, hydraulic, pneumatic, kinetic, thermal, chemical, etc.) was isolated in accordance with Chevron 1. Locks and tags used for isolations indicated the identity of the individual who applied the device. 2. Lockout devices were used to place equipment in a safe working condition or off position. 3. Isolations were visibly verified and isolation points were documented in an isolation log, checklist or special permit/certificate prior to starting work. 4. Isolations were communicated to the work crew and all other impacted work crews. 5. All permits were documented and kept at the worksite. Lifting and Rigging: Lifting and rigging work was performed in accordance with Chevron 1. n-certified fabricated or modified lifting and rigging equipment was not used. 2. Lifting and rigging equipment was inspected prior to use; inspections were documented 3. Pick up and lay down zones were established, visible and free of obstructions, debris and personnel. 4. Lifting and rigging work was conducted by qualified/certified operators, riggers and signalmen. 5A. Was the lift a critical and/or non-routine lift (including complicated, complex, heavy, blind and personnel lifts)? (If no, skip question 5B) 5B. A lift plan was documented and kept at the worksite. 6A. Was the lift being conducted around/near overhead power lines? (If no, skip question 6B) 6B. Lifting and rigging equipment maintained minimum clearance distances from overhead power lines. Portable Gas Detection: Gas detection was conducted in accordance with Chevron 1. Gas testing was conducted; results were documented and within acceptable limits prior to starting work activity. 2. Portable gas detection equipment was field verified for accuracy (functional/bump test). 3. Gas testing was performed by a qualified gas tester. 4

5 Work at Heights: Work at height was conducted in accordance with Chevron 1. Crew members working at height wore fall prevention/protection gear. 2. Rescue teams and equipment were readily available to respond to work at height emergencies. 3. Rescue plans for work at height were documented and communicated to the work crew. 4. A safety standby was onsite while work was performed at height to monitor work conditions and notify rescue personnel in the event of a fall. 5. All permits were documented and kept at the worksite. 6A. Did the work at height involve the construction, inspection, maintenance and use of scaffolding? (If no, skip question 6B) 6B. Scaffolding and scaffolding components was inspected prior to use; inspections were documented. 7A. Did the work at height take place around/near overhead power lines? (If no, skip question 7B) 7B. Equipment (e.g. scaffolds, MEWPS, etc.) maintained minimum clearance distances form overhead power lines. Control of Static Electricity: Static electricity was controlled during the transfer of flammable/combustible liquids in accordance with Chevron 1. Vacuum truck connections were bonded and grounded. 2. Bonding and grounding connections were tested; testing/verification was documented. 3. Bonding clamps had hardened steel points to displace paint and rust. 4. Only conductive hoses or equivalent grounded/bonded systems were used. 5. Hoses and connectors were visually inspected prior to use. Was feedback provided to the work team during the close-out of this engagement? 5