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QEW 1 / 2 / 3 Job Safety Plan

Electrical Safety
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Time / Date: 2/6/2025 9:14:58
JSP ID: 3344
Scope of Work: Replace GFCI in sector 12 on bench

General Information

Work Order
WO415067
Building
ALS bldg6
Person in Charge
Mayumi Taylor
Lead / Supervisor
Keusch, Justen
Logged Email
mayumijeantaylor@gmail.com
Division
ALS

Work Planning

Modes of Work
☑ Mode 0 - Electrically Safe Work Condition
☑ Mode 1 - LOTO & Zero Voltage Verification
QEW Level
QEW 2
Second Person Requirement
Standby Person
Second Person Identified
Beau Erwin
Other Participants
N/A
Affected Persons Notified
Yes

System / Equipment

Switching
Non-Hazardous Switching
Panel / Equipment ID
277A
System Information Review
☑ Panel Schedules
☑ Arc Flash Labels
Control of Hazardous Energy
Complex LOTO (requires LP, CLP, FLP)
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
Loto, ZVV, replace and test receptacles

Control of Work Area

Minimum Approach Boundary
42 inches
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
0
Will any other part of the body enter the RAB
No

Arc Flash Risk Assessment

Incident Energy
1.2 cal/cm2 cal/cm2
Arc Flash Boundary
18 inches
Working Distance
18 inches
Arc Flash PPE Level
2
Incident Energy Reduction Measures
0

Capacitor Hazards

Capacitor Bus Voltage
N/A
Capacitor Total Stored Energy (Joules)
N/A
Discharge Wait Time (Minutes)
N/A

Emergency Response Plan

Nearest Landline Location
Sector 1
Emergency Number to Call
911
Sufficient Cell Phone Signal
Yes
Clear Exit Path
Yes
AED Location
ALS lobby
Fire Extinguisher Location
Hallway
Contact Release Method Available and Tested
Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?
Insufficient/cramped/awkward space, Heavy traffic

Error Precursors

Task Demands
Repetitive actions or monotony
Work Environment
Distractions/interruptions, Unexpected equipment conditions
Individual Capabilities
Human Nature
Assumptions
Error Precursor Mitigations
None

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
☑ Multimeter and other electrical test instruments

Notes / Other

Perform Job Briefing

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 2026.03.17.1
Form Content and Feedback Contact: Michael Rose -- mvr@lbl.gov