Time / Date: 8/31/2022 15:28:45
JSP ID: 3
Scope of Work: Test
Work Order: 99999
Building:
Person in Charge: M Rose
Lead / Supervisor: M Rose
Logged Email: mvr@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement:
Second Person Identified:
List Other Participants:
Affected Persons Notified:
Switching:
Panel / Equipment ID: 234A
System Information Review:
Control of Hazardous Energy:
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.

Control of Work Area

Minimum Approach Boundary: 46
Barricade Tape / Attendant: Warning

Shock Risk Assessment

System Voltage: 277/480 Vac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 12 inches
Will the hands enter the RAB: Yes
Voltage Glove Class: 0
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 5.6 cal/cm2
Arc Flash Boundary: 54 in
Working Distance: 18 inches
Arc Flash PPE Level: 2
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: B75
Emergency Number to Call: 510-486-6999
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: S Wall
Fire Extinguisher Location: Outside back door
Contact release method available and tested: Upstream breaker or switch, Rescue hook

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Insufficient lighting

Error Precursors

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

Distracted, will use STAR method

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