Time / Date: 7/24/2023 9:40:03
JSP ID: 1297
Scope of Work: Reset tripped breaker feeding receptacles in 1275
Work Order:
Building: 50B
Person in Charge: Andrew Southward
Lead / Supervisor: Cameron, Benjamin
Logged Email: amsouthward@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: Alma Duran
List Other Participants:
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: 38A10A5A
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
Equipment Condition: Properly installed, 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.

Unplug equipment from receptacles, inspect for likely cause of tripped breaker, obtain permission from engineering to switch( over dutied panel) reset breaker and switch on.

Control of Work Area

Minimum Approach Boundary: 42
Barricade Tape / 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: 0.42 cal/cm2
Arc Flash Boundary: 10 inches
Working Distance: 18 inches
Arc Flash PPE Level: 1
Incident Energy Reduction Measures: Not Required

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: 1275
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: On hand
Fire Extinguisher Location: Outside 1275
Contact release method available and tested: Upstream breaker or switch, Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Lookalike equipment, Noisy environment, Over duty panel

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.,
Hearing protection,
Rubber insulating gloves and leather protectors,
Non-melting footwear that fully covers the feet,
Removal of conductive articles,
Insulated tools,
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