Time / Date: 3/27/2024 7:12:19
JSP ID: 2370
Scope of Work: Contractor Support
Work Order: W0373266
Building: building 36
Person in Charge: Avery Turner
Lead / Supervisor: Cameron, Benjamin
Logged Email: avery.turner08@gmail.com
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition
Second Person Requirement: Not Required
Second Person Identified: N/A
List Other Participants: contractors
Affected Persons Notified: N/A
Switching: No Switching Required
Panel / Equipment ID: N/A
System Information Review: Single Line Drawing, Panel Schedules
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.

Hold safety meeting with contractor.

Control of Work Area

Minimum Approach Boundary: 10 feet
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: No Shock Hazard Present
Limited Approach Boundary: 10 feet
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: N/A cal/cm2
Arc Flash Boundary: N/A
Working Distance: 10 feet
Arc Flash PPE Level: 2+
Incident Energy Reduction Measures: Not Required

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: building 36
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: yes
Fire Extinguisher Location: building 36
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.,
Hearing protection,
Rubber insulating gloves and leather protectors,
Non-melting footwear that fully covers the feet,
Removal of conductive articles,
Insulated tools,
Multimeter and other electrical test instruments

Notes / Other

none

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