Time / Date: 6/29/2023 13:34:39
JSP ID: 1196
Scope of Work: Troubleshoot laser interlock issues
Work Order: 326945
Building: 2-0328
Person in Charge: E combs
Lead / Supervisor: Keusch, Justen
Logged Email: ccryken@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 2 - Energized Diagnostics, Testing and Troubleshooting, Visual Inspection
Second Person Requirement: Not Required
Second Person Identified:
List Other Participants:
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 247A2A4A
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, Not energizing equipment for the first time, or after electrical repair

Sequence of Job Steps

List basic sequence of steps from start to finish.

Determine issue, resolve issue

Control of Work Area

Minimum Approach Boundary: 48”
Barricade Tape / Attendant: Notice - Blue, Attendant

Shock Risk Assessment

System Voltage: No Shock Hazard Present
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 3 feet, 6 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: O.23 cal/cm2
Arc Flash Boundary: 7 inches
Working Distance: N/A
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: In lab
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Bldg 2 each floor elevator lobby
Fire Extinguisher Location: In lab
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),
Non-melting footwear that fully covers the feet

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