Time / Date: 4/7/2025 8:19:44
JSP ID: 3584
Scope of Work: LOTO circuits to be relocated
Work Order: 415067
Building: 80 011A
Person in Charge: Christopher Nelson
Lead / Supervisor: Combs, Everett
Logged Email: cnelsom@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: David Davis
List Other Participants:
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 579A
System Information Review: Panel Schedules, Arc Flash Labels, ALS complex LOTO form
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.

Fill out jha JSP als complex LOTO form switch LOTO ZVV and then do work when work is completed release the LOTO and switch back on circuits

Control of Work Area

Minimum Approach Boundary:
Barricade Tape / Attendant: Warning - Orange

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 3 feet, 6 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: 5.03 cal/cm2
Arc Flash Boundary: 40
Working Distance: 18 inches
Arc Flash PPE Level: 1
Incident Energy Reduction Measures: 0

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: Down the hall near fire extinguishers
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: In b 15
Fire Extinguisher Location: Down the hall by room 012
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: Distractions/interruptions
Individual Capabilities:
Human Nature: Habit patterns
Error Precursor Mitigations:

Be aware and alert to any situation

PPE Inspections

Safety glasses (ANSI Z87),
Arc-rated clothing (flash suit,
daily wear) including face shield,
balaclava,
hood.,
Hearing protection,
Non-melting footwear that fully covers the feet,
Removal of conductive articles,
Insulated tools,
Multimeter and other electrical test instruments

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