Time / Date: 1/17/2024 7:15:04
JSP ID: 2090
Scope of Work: Lock out breaker for FA panel, ZVV, install CP-35, re-energize FA
Work Order: Training
Building: 75A
Person in Charge: Noel Cuffee
Lead / Supervisor: Gomez, Rudy
Logged Email: eacuffee@gmail.com
Division: Facilities
QEW Level: QEW 1
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Not Required
Second Person Identified: Mike Rose
List Other Participants: N/A
Affected Persons Notified: N/A
Switching: Hazardous Switching
Panel / Equipment ID: Siemens system 3 FA panel
System Information Review: Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
Equipment Condition: Properly installed, No signs of impending failure

Sequence of Job Steps

List basic sequence of steps from start to finish.

Lock out breaker for FA panel, ZVV, install CP-35, re-energize FA

Control of Work Area

Minimum Approach Boundary: 42”
Barricade Tape / Attendant: Warning - Orange, Danger - Red

Shock Risk Assessment

System Voltage: 120 Vac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 3 inches
Will the hands enter the RAB: Yes
Voltage Glove Class: 0
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 1.2 cal cal/cm2
Arc Flash Boundary: Warning tape and sign
Working Distance: No Arc Flash Hazard Present
Arc Flash PPE Level: Minimum PPE for Electrical Work
Incident Energy Reduction Measures: 0

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: B75
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Near FA panel
Fire Extinguisher Location: Outside the back door
Contact release method available and tested: Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

None

Error Precursors

Task Demands: Time pressure (in a hurry)
Work Environment:
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

No time constraints

PPE Inspections

Safety glasses (ANSI Z87),
Rubber insulating gloves and leather protectors,
Non-melting footwear that fully covers the feet,
Insulated tools,
Multimeter and other electrical test instruments

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