Time / Date: 10/19/2022 11:54:22
JSP ID: 116
Scope of Work: Test test
Work Order: 0123456
Building:
Person in Charge: Mike Rose
Lead / Supervisor: Other
Logged Email: mvr@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Me
List Other Participants: None
Affected Persons Notified: N/A
Switching: Non-Hazardous Switching
Panel / Equipment ID: 234A
System Information Review: Single Line Drawing, Panel Schedules
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, Not energizing equipment for the first time, or after electrical repair

Sequence of Job Steps

List basic sequence of steps from start to finish.

5640 65406504 65406 654063 6406

Control of Work Area

Minimum Approach Boundary: 406
Barricade Tape / Attendant: Danger, Attendant

Shock Risk Assessment

System Voltage: 120/208 V ac
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: 5.6 cal/cm2
Arc Flash Boundary: 39
Working Distance: 18 inches
Arc Flash PPE Level: 2
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: B78
Emergency Number to Call: 7911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Drawer
Fire Extinguisher Location: Right outside
Contact release method available and tested: Upstream breaker or switch, Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Insufficient lighting

Error Precursors

Task Demands: Time pressure (in a hurry)
Work Environment: Distractions/interruptions, Obscure electrical supplies or configurations
Individual Capabilities: Imprecise communication habits, Indistinct problem-solving skills
Human Nature: Assumptions, Complacency/overconfidence
Error Precursor Mitigations:

None

PPE Inspections

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