Time / Date: 1/4/2024 8:35:33
JSP ID: 2037
Scope of Work: Turn on lighting circuits that are not functioning as programmed
Work Order: 360865
Building: 15
Person in Charge: E combs
Lead / Supervisor: Combs, Everett
Logged Email: ccryken@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: Non-Hazardous Switching
Panel / Equipment ID: Watt stopper LCP Bldg 15 2nd floor electrical room
System Information Review: Finger safe
Control of Hazardous Energy: LOTO Not Required (Mode 2 or 3 only)
Equipment Condition: Properly installed

Sequence of Job Steps

List basic sequence of steps from start to finish.

Manually close relay switches in Lighting Control Panel

Control of Work Area

Minimum Approach Boundary: Not applicable
Barricade Tape / Attendant: 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: Not applicable cal/cm2
Arc Flash Boundary: Not applicable
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: 2nd floor copy room
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Bldg 15 1st floor lobby
Fire Extinguisher Location: 2nd floor
Contact release method available and tested: Not applicable

Environmental Conditions

Does the environment present additional hazards that should be addressed?

None

Error Precursors

Task Demands: Time pressure (in a hurry)
Work Environment: Obscure electrical supplies or configurations
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

Not applicable

PPE Inspections

Safety glasses (ANSI Z87)

Notes / Other

LCP needs to be reprogrammed

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