Time / Date: 5/17/2023 8:28:20
JSP ID: 1046
Scope of Work: Install nema 3 can and new junction box and weather proof cover.
Work Order: 326168
Building:
Person in Charge: Armand uribe
Lead / Supervisor: Secheck, Stephen
Logged Email: Auribe@lbl.gov
Division: Facilities
QEW Level: QEW 1
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Jared Tissot
List Other Participants:
Affected Persons Notified: N/A
Switching: Non-Hazardous Switching
Panel / Equipment ID: 38A4B1A
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
Equipment Condition: Properly installed, Properly maintained, All doors and covers closed and fully latched, No signs of impending failure

Sequence of Job Steps

List basic sequence of steps from start to finish.

JSP, PPE inspection, job brief, lotto CT, ZVV receptacle, perform work.

Control of Work Area

Minimum Approach Boundary: 42”
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: No Shock Hazard Present
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 12 inches
Will the hands enter the RAB: No
Voltage Glove Class: Not Required
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 0.33 cal/cm2
Arc Flash Boundary: 8”
Working Distance: 18 inches
Arc Flash PPE Level: Minimum PPE for Electrical Work
Incident Energy Reduction Measures: Not Required

Capacitor Hazards

Capacitor Bus Voltage:
Capacitor total stored energy (joules):
Discharge wait time (minutes):

Emergency Response Plan

Nearest Landline Location: Across the hall
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: In the corridor
Fire Extinguisher Location: Corridor
Contact release method available and tested: Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

None

Error Precursors

Task Demands:
Work Environment:
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

None

PPE Inspections

Safety glasses (ANSI Z87),
Arc-rated clothing (flash suit,
daily wear) including face shield,
balaclava,
hood.,
Rubber insulating gloves and leather protectors,
Multimeter and other electrical test instruments

Notes / Other

Perform Job Breifing

PIC Conducts the Job Briefing. Cover all the contents of the Job Safety Plan.

A Job Briefing at a minimum must include:
  1. Detailed Scope of Work
  2. Shock and arc flash hazards for each task
  3. Controls to mitigate the hazards (procedures, precautions, energy source controls, PPE requirements)
  4. Work area controls (barricades, signs, attendants)
  5. Emergency Response Plan

Rev 2023.08.22.1
Form Content and Feedback Contact: Michael Rose -- mvr@lbl.gov