Time / Date: 8/1/2023 9:14:43
JSP ID: 1334
Scope of Work: Confirm 120v AC Control Power to FPU panel 48-2A
Work Order: W0323595
Building: 48 Electric Room 103
Person in Charge: Joseph Pica
Lead / Supervisor: Cameron, Benjamin
Logged Email: josephpica@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition
Second Person Requirement: Safety Watch
Second Person Identified: AJ Turner
List Other Participants: None
Affected Persons Notified: Yes
Switching: No Switching Required
Panel / Equipment ID: 155A1A, 48FPU-2A
System Information Review: Single Line Drawing, Panel Schedules, Arc Flash Labels, as Necessary
Control of Hazardous Energy: LOTO Not Required (Mode 2 or 3 only)
Equipment Condition: 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.

Apply Circuit Tracer to Panel 155A1A circuits to Identify 48FPU-2A control power feed (starting with 30)

Control of Work Area

Minimum Approach Boundary: 42”
Barricade Tape / Attendant: 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: 0
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 9.75cal cal/cm2
Arc Flash Boundary: 67”
Working Distance: 18 inches
Arc Flash PPE Level: 4
Incident Energy Reduction Measures: 0

Capacitor Hazards

Capacitor Bus Voltage: No Capacitor
Capacitor total stored energy (joules): No Capacitor
Discharge wait time (minutes): No Capacitor

Emergency Response Plan

Nearest Landline Location: Adjacent Security Office
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: On Site
Fire Extinguisher Location: On Site
Contact release method available and tested: Upstream breaker or switch, 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:

Verbatim Repeat Back

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

Notes / Other

Hazardous Energy Controls Not Applicable No LOTO Necessary No Mode 2 or 3 Work Circuit Trace

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