Time / Date: 4/9/2025 10:12:27
JSP ID: 3599
Scope of Work: PM
Work Order: 426139
Building: 33
Person in Charge: Capeto
Lead / Supervisor: Delgado, Alex
Logged Email: mcapeto@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Walker
List Other Participants: None
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: E642A3A/ 33 AC 005
System Information Review: No arc flash
Control of Hazardous Energy: Simple LOTO
Equipment Condition:

Sequence of Job Steps

List basic sequence of steps from start to finish.

Switch, LOTO, ZVV, PM, release LOTO, switch, verify ops

Control of Work Area

Minimum Approach Boundary: 42”
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: None
Restricted Approach Boundary: None
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: NA cal/cm2
Arc Flash Boundary: NA
Working Distance: 24 inches
Arc Flash PPE Level: Minimum PPE for Electrical Work
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: Room345
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Lobby
Fire Extinguisher Location: Outside women’s bathroom
Contact release method available and tested: Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Fall hazard

Error Precursors

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

Reviewed

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 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