Time / Date: 11/16/2022 10:23:40
JSP ID: 247
Scope of Work: Replace lighting power pack 2nd fl. 285 corridor
Work Order: 301863
Building:
Person in Charge: Christopher Nelson
Lead / Supervisor: Secheck, Stephen
Logged Email: cnelson@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Alex lopez
List Other Participants: Alex lopez
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 671A2A3A
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
Equipment Condition: Properly installed, Properly maintained, All doors and covers closed and fully latched, No signs of impending failure, Not energizing equipment for the first time, or after electrical repair

Sequence of Job Steps

List basic sequence of steps from start to finish.

Switch LOTO ZVV replace device re energize call controls Matt Rivas

Control of Work Area

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

Shock Risk Assessment

System Voltage: 277/480 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 12 inches
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: .78 cal/cm^2 cal/cm2
Arc Flash Boundary: 14”
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:
Capacitor total stored energy (joules):
Discharge wait time (minutes):

Emergency Response Plan

Nearest Landline Location: Room 210
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: 2nd fl. Lobby
Fire Extinguisher Location: Within 15 ft
Contact release method available and tested: Upstream breaker or switch

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Heavy traffic

Error Precursors

Task Demands:
Work Environment:
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

Be aware stop work if something isn’t right

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