Time / Date: 6/28/2024 9:38:11
JSP ID: 2707
Scope of Work: Open bottom of MCC to take pictures of underground conduits.
Work Order: 382896
Building: 6
Person in Charge: Robert Ralph
Lead / Supervisor: Combs, Everett
Logged Email: RobertRalph@lbl.gov
Division: ALS
QEW Level: QEW 2
Modes of Work: Mode 2 - Energized Diagnostics, Testing and Troubleshooting, Visual Inspection
Second Person Requirement: Safety Watch
Second Person Identified: Chris Nelson
List Other Participants:
Affected Persons Notified: N/A
Switching: No Switching Required
Panel / Equipment ID: M304A3A
System Information Review: Arc Flash Labels
Control of Hazardous Energy: LOTO Not Required (Mode 2 or 3 only)
Equipment Condition: Properly installed, Properly maintained

Sequence of Job Steps

List basic sequence of steps from start to finish.

1. Job briefing 2. Barricade with Danger3.Put on appropriate PPE 4.Open MCC 5.Take photos 6.close MCC 7.remove barricades.

Control of Work Area

Minimum Approach Boundary: 42
Barricade Tape / Attendant: Danger - Red

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: 11 cal/cm2
Arc Flash Boundary: 69”
Working Distance: 18 inches
Arc Flash PPE Level: 4
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: Lobby B6
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Lobby B6
Fire Extinguisher Location: By column 5
Contact release method available and tested: Voltage gloves

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:

Make sure all precursors have been discussed.

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

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