Time / Date: 12/21/2023 8:27:19
JSP ID: 2009
Scope of Work: Trouble shoot light issue in room 15-0217
Work Order: 359879
Building: 15-0217
Person in Charge: C.ryken
Lead / Supervisor: Combs, Everett
Logged Email: ccryken@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 2 - Energized Diagnostics, Testing and Troubleshooting, Visual Inspection
Second Person Requirement: Not Required
Second Person Identified:
List Other Participants:
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: Watt stopper LCP
System Information Review: Panel Schedules
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.

Control of Work Area

Minimum Approach Boundary:
Barricade Tape / Attendant:

Shock Risk Assessment

System Voltage: No Shock Hazard Present
Limited Approach Boundary: None
Restricted Approach Boundary: None
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: 0 cal/cm2
Arc Flash Boundary: 42 inches
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? Yes
Clear exit path? Yes
AED Location: Bldg15 lobby
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:

None

PPE Inspections

Safety glasses (ANSI Z87),
Arc-rated clothing (flash suit,
daily wear) including face shield,
balaclava,
hood.,
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