Time / Date: 10/31/2022 14:02:05
JSP ID: 169
Scope of Work: Install 3 pole breaker blank in panel 249A B2-412
Work Order: W0300501
Building:
Person in Charge: Greg Neidiger
Lead / Supervisor: Secheck, Stephen
Logged Email: gcn@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition
Second Person Requirement: Not Required
Second Person Identified:
List Other Participants:
Affected Persons Notified: N/A
Switching: No Switching Required
Panel / Equipment ID: 249A
System Information Review: Arc Flash Labels
Control of Hazardous Energy: LOTO Not Required (Mode 2 or 3 only)
Equipment Condition:

Sequence of Job Steps

List basic sequence of steps from start to finish.

Get part number for purchasing material

Control of Work Area

Minimum Approach Boundary:
Barricade Tape / Attendant:

Shock Risk Assessment

System Voltage: No Shock Hazard Present
Limited Approach Boundary: n/a
Restricted Approach Boundary: n/a
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: n/a cal/cm2
Arc Flash Boundary: n/a
Working Distance: No Arc Flash Hazard Present
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:
Emergency Number to Call:
Sufficient cell phone signal?
Clear exit path?
AED Location:
Fire Extinguisher Location:
Contact release method available and tested:

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:

n/a

PPE Inspections

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