Time / Date: 11/4/2022 13:05:58
JSP ID: 196
Scope of Work: EM work order to investigate west stairwell lighting circuit. Identify circuit.
Work Order: 300996
Building:
Person in Charge: Shane Miller
Lead / Supervisor: Secheck, Stephen
Logged Email: spmiller@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification, Mode 2 - Energized Diagnostics, Testing and Troubleshooting, Visual Inspection
Second Person Requirement: Standby Person
Second Person Identified: NIck Gripe
List Other Participants: Alex Lopez, Chris Nelson
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 140A1A
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

Sequence of Job Steps

List basic sequence of steps from start to finish.

Dawned the proper PPE and located a Jbox that was for the circuit in question. Attached a circuit tracer to wire and went to probable panel and identified circuit.

Control of Work Area

Minimum Approach Boundary:
Barricade Tape / Attendant: 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: No
Voltage Glove Class: 00
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 0.23cal/cm^2 cal/cm2
Arc Flash Boundary: 18"
Working Distance: 18 inches
Arc Flash PPE Level: Minimum PPE for Electrical Work
Incident Energy Reduction Measures: 00

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: 70b
Emergency Number to Call: x6999
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location:
Fire Extinguisher Location:
Contact release method available and tested: Upstream breaker or switch

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:

none

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