Time / Date: 2/26/2025 13:12:42
JSP ID: 3446
Scope of Work: TEST
Work Order: TEST
Building: B-92
Person in Charge: Luis Perez
Lead / Supervisor: Other
Logged Email: danwilliams@lbl.gov
Division: Other
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification, Mode 2 - Energized Diagnostics, Testing and Troubleshooting, Visual Inspection
Second Person Requirement: Safety Watch
Second Person Identified: Bill Wright
List Other Participants: Laurence Dwong
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: TEST
System Information Review: Single Line Drawing, 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.

TEST TEST2 TEST3 TESTY

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: Yes
Voltage Glove Class: 0
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 104.8 cal/cm2
Arc Flash Boundary: 15"
Working Distance: 18 inches
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

Capacitor Bus Voltage: na
Capacitor total stored energy (joules): na
Discharge wait time (minutes): 5 mins

Emergency Response Plan

Nearest Landline Location: Burger King on University
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: 92
Fire Extinguisher Location: 92
Contact release method available and tested: Rescue hook

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Insufficient lighting, Wet location, Confined space, Insufficient/cramped/awkward space, Heavy traffic, Fall hazard, Lookalike equipment

Error Precursors

Task Demands: Simultaneous or multiple tasks
Work Environment: Confusing displays or controls
Individual Capabilities: New technique not used before
Human Nature:
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

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