Time / Date: 9/5/2023 12:50:52
JSP ID: 1500
Scope of Work: Reset breaker for lighting inverter in panel DP E671A11A and leave open. Switch lighting inverter to bypass
Work Order:
Building: 91
Person in Charge: Andrew Southward
Lead / Supervisor: Cameron, Benjamin
Logged Email: alarmentaduran@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Safety Watch
Second Person Identified: Ben Cameron / Alma Armenta
List Other Participants: Justen Keusch
Affected Persons Notified: N/A
Switching: Hazardous Switching
Panel / Equipment ID: E671A11A Ct 3
System Information Review: 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.

Ensure equipment okay to be reset and left open. Don adequate PPE. Switch/LOTO with admin lock

Control of Work Area

Minimum Approach Boundary: 42”
Barricade Tape / Attendant:

Shock Risk Assessment

System Voltage: 277/480 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: 4.03 cal/cm2
Arc Flash Boundary: 38”
Working Distance: 18 inches
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

Capacitor Bus Voltage: None
Capacitor total stored energy (joules): None
Discharge wait time (minutes): None

Emergency Response Plan

Nearest Landline Location: In electrical room
Emergency Number to Call: 5104867911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: On hand
Fire Extinguisher Location: By front door of building 91
Contact release method available and tested: Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Lookalike equipment

Error Precursors

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

None

PPE Inspections

Safety glasses (ANSI Z87),
Rubber insulating gloves and leather protectors,
Non-melting footwear that fully covers the feet,
Removal of conductive articles

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