Time / Date: 9/5/2023 8:13:32
JSP ID: 1497
Scope of Work: Trace and identify all loads from panel 193A
Work Order: W0342001
Building: 72
Person in Charge: Andrew Southward
Lead / Supervisor: Cameron, Benjamin
Logged Email: amsouthward@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 2 - Energized Diagnostics, Testing and Troubleshooting, Visual Inspection
Second Person Requirement: Safety Watch
Second Person Identified: Alma Duran
List Other Participants:
Affected Persons Notified: N/A
Switching: No Switching Required
Panel / Equipment ID: 193A
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: LOTO Not Required (Mode 2 or 3 only)
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.

Establish safe work area, access panel 193A, install circuit tracer, go to downstream loads and use receiver to identify signal, remove tracer after loads have been identified

Control of Work Area

Minimum Approach Boundary: 61
Barricade Tape / Attendant: Danger - Red

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: Yes
Voltage Glove Class: 0
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 10.8 cal/cm2
Arc Flash Boundary: 61 “
Working Distance: 18 inches
Arc Flash PPE Level: 2+
Incident Energy Reduction Measures: 0

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: 72 first floor
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: On hand
Fire Extinguisher Location: 72 first floor hallway
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/cramped/awkward space

Error Precursors

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

Na

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