Time / Date: 11/8/2022 14:13:25
JSP ID: 207
Scope of Work: Implicate loto
Work Order: 302028
Building:
Person in Charge: Beau erwin
Lead / Supervisor: Secheck, Stephen
Logged Email: jgerwin@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Not Required
Second Person Identified:
List Other Participants:
Affected Persons Notified:
Switching: Non-Hazardous Switching
Panel / Equipment ID: 39A7A
System Information Review: Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
Equipment Condition:

Sequence of Job Steps

List basic sequence of steps from start to finish.

Verified circuits that light fixture in question.. switched open breaker.. put administrative lock on breaker. Job completed

Control of Work Area

Minimum Approach Boundary:
Barricade Tape / Attendant:

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: Avoid contact
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: 3.93 cal/cm2 cal/cm2
Arc Flash Boundary: 38”
Working Distance: 38 in
Arc Flash PPE Level: 1
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:
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?

Wet location

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