Time / Date: 3/27/2024 7:22:29
JSP ID: 2371
Scope of Work: Contractor Support
Work Order: W0373266
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: none
List Other Participants: contractor
Affected Persons Notified: N/A
Switching: No Switching Required
Panel / Equipment ID: n/A
System Information Review:
Control of Hazardous Energy: Exclusive Control of Plug
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:
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: above greater then ten feet
Limited Approach Boundary: 10 feet
Restricted Approach Boundary: 120
Will the hands enter the RAB: No
Voltage Glove Class: 0
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: none cal/cm2
Arc Flash Boundary: none
Working Distance: 120 inches
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

Capacitor Bus Voltage: none
Capacitor total stored energy (joules):
Discharge wait time (minutes): none

Emergency Response Plan

Nearest Landline Location: building 36
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? No
AED Location: yes
Fire Extinguisher Location: yes
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:
Work Environment:
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

None

PPE Inspections

Safety glasses (ANSI Z87),
safety glasses

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