Time / Date: 11/22/2022 7:33:42
JSP ID: 258
Scope of Work: Preform switching and loto of branch circuit in order to temporarily remove lighting fixtures attached to shelving.
Work Order: 300515
Building:
Person in Charge: Jared tissot
Lead / Supervisor: Ramer, Robert
Logged Email: jtissot@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Not Required
Second Person Identified: NA
List Other Participants: Carpenters
Affected Persons Notified: N/A
Switching: Non-Hazardous Switching
Panel / Equipment ID: 462A21A-1
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 circuit, preform loto, preform zvv, remove light fixtures and install KO seal on wire mold. Release loto and energize circuit

Control of Work Area

Minimum Approach Boundary: 64”
Barricade Tape / Attendant:

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 12 inches
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: 11.9 cal/cm2
Arc Flash Boundary: 64
Working Distance: 18 inches
Arc Flash PPE Level: Minimum PPE for Electrical Work
Incident Energy Reduction Measures: Not Required

Capacitor Hazards

Capacitor Bus Voltage: NA
Capacitor total stored energy (joules): NA
Discharge wait time (minutes): NA

Emergency Response Plan

Nearest Landline Location: B84
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: B84
Fire Extinguisher Location:
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

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